Humpty-Dumpty and the hidden agenda

September 2005

Humpty-Dumpty sat on a wall.

Humpty-Dumpty had a great fall.

All the king’s horses and all the king’s men

Couldn’t put Humpty together again.

Some things are just not learned in medical school. Like how to age gracefully. I am not getting older. That, my friends, is the truest fiction that my mind can concoct. But it seems as though lately, I see the children of my former patients.

Some could misconstrue this as my aging process. But I look at this “glass half-full” phenomenon as the ultimate compliment a physician could receive and ignore the derogatory chiding. I also interpret this to mean that I had treated these former patients so well that they want to bring back their own special progeny to seek my sage advice, my superb clinical acumen and, well, let’s be honest, to hear me crack my inane self-deprecatory jokes and to make fun of my goofiness again. And since our practice has a stable population base, I may see parents who are my former patients for about two-thirds of the day.

This phenomenon also provides me with some incredible rapport, which may be used advantageously sometimes.

A family I have seen for years, a young mother, who has three children ages 2, 6 and 8, made an appointment without her daughter. She and her estranged husband recently moved back into the community. She wanted to discuss the worsening anxiety that her overly sensitive daughter had developed.

The child had trouble sleeping at night, and was even developing some school avoidance symptoms.

Hidden agenda

I have known this pleasant mother since she was in high school, and have had several casual conversations with her as a youngster and in the office about her children over the years. I also once provided medical care for her husband when he was a teenager.

Before they moved away five years ago, I even figured out what was causing this strange bleeding diathesis that her two daughters had developed, with elevated partial thromboplastin times (PTT) and severe epistaxis, even requiring overnight nasal packing. This problem had perplexed the hematologist and me for months, despite an extensive hematologic work-up. Then I said, “Ask your grandmother (originally from Europe), who has been baby-sitting for the children, if she ever gives the children any herbal concoctions or ‘medicines.’” All epistaxis subsided and the PTT returned to normal within a week and forever.

Time to put down the stethoscope and the otoscope. Do I open Pandora’s Box of open-ended discussion, and prod her for the real problems? “How are you doing lately? How is your husband? And your relationship? Have you been eating? Sleeping?” Many intermittent tearful moments ensued.

In this case, the center of this little girl’s universe had fallen apart, because her mother had fallen apart as her marriage disintegrated. The mother looked stressed and had probably dropped 10 pounds from her already gaunt frame. Her husband had moved out again, even though I had just seen them reconciling last month. I inquired: “Have you been eating lately?” “Not for the last two weeks.” “What changed?”

Then she unloaded: after the move away, their relationship had become strained; he worked two jobs to keep up their “necessary income,” he never doted on her nor helped out enough with the children. And she resented him; she declared she had no life outside the children and wanted to work, but could not because they were too far from family with their move and he was never home.

She had mixed feelings — more like osterized feelings — about their relationship. And the romance had faded. Her passive-aggressive defense mechanisms abounded. But things had been nurtured since the move back home until a hydrogen bomb had been dropped that decimated her universe again. The young mother had just received a phone call from her husband’s “Internet sweetheart” with whom he had terminated a year-long relationship — declaredly platonic — several months earlier. But then who could fault two years of being shoved away by a spouse? Both parties — guilty as charged.

“Could you ever trust him again?” “We are going to see a marriage counselor soon.”

Don Quixote

I could have let this drop, but I had one real advantage over a new marriage counselor — both parties knew me and trusted me. Should I rely on “All the king’s horses and all the king’s men”? Or would my office schedule be in shambles today? Plus, this family was insured by a capitated HMO (ie, You aren’t going to get paid a cent more, Buster.)

Don Quixote had nothing over on me, so I proceeded.

I inquired about her perception of him: “Love each other? Still in love?” “Madly.” “Great Daddy to the kids? No drugs or alcohol problems? Willing to work hard to provide?

“Some people spend a lifetime trying to find Mr. or Mrs. Right. Just see all the single cynical mothers and fathers in my practice.

“Time to gamble on him again?” I cajoled. She agreed the odds were actually good. Talk about an uncertain diagnosis! She was still irate, but the kids adored their father. I reminded her that, regardless of her decision, she had to start eating again. That one stunned her. As Yeats said, “The center cannot hold,” if the mother turns anorexic, beating up herself. She would try.

We instituted sertraline for the overly anxious daughter with appropriate warnings and follow-up assured.

She left profusely grateful.

For you cynics, actually, I believe that we made money from this prolonged visit. (See, I told you the glass was half full.) Perhaps this marriage with some happiness was salvageable. Then the three children would not require umpteen capitated visits for multiple stress-related, school avoidance and psychosomatic complaints over the next year. Selective serotonin reuptake inhibitors and gastrointestinal drugs will likely not be necessary. I hoped not to see another potentially good family, which should be able to survive, crack like Humpty-Dumpty from a great fall due to self-centeredness on both parts. Call me Pollyanna.

As I entered the room for the next patient, greeted with stern looks, I cowered and apologized for my tardiness. Thankfully, the older parent warmed up and smiled when I hinted that I attempted to save a young marriage, which is just as important as attempting to save lives in medicine sometimes.

For more information:

• Stan L. Block, MD, has a pediatric practice in Bardstown, Ky., and is a member of the Infectious Diseases in Children editorial board.