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Recognizing Scars of the Mind

“This one is a handful. She brought a long list, too, so good luck with that,” the nurse said as she handed me the patient prep sheet.

This was a new patient to the family medicine practice. I was seeing her near the end of a long day, so I took a deep breath to reset my mind as I entered the exam room, prepared to listen.

As trained, I asked, “What brings you in today?”

In a soft voice she said, “Well, I have a few things. I wrote a list on my phone and I want to make sure you know them all. I haven’t been to a doctor in a long time and I want to get healthier.”

Given only 15 minutes per visit, I was tempted to interrupt her while she itemized her issues in detail: bilateral shoulder and hip pain, right foot pain, claustrophobia, depression, difficulty sleeping, worsening dyspnea and a few others.

She seemed a little restless as she fidgeted with her phone and moved around in her chair while speaking. I noticed I was feeling uneasy as well.

“You did the right thing coming in today,” I followed to comfort her. “Since we have a limited amount of time, I wrote out a list with details to make sure we won’t forget anything. I feel your shortness of breath may be a bit concerning, so how about we focus on that today and then set up a follow-up appointment for your other concerns?”

She persisted, “I’m so sorry I have so much going on, but I want to get better and these are all really bothering me. If you can tell me a few things I can work on until next time, I promise I will do it.”

Her restless energy was palpable. I suddenly felt anxious and overwhelmed, echoing the emotions of my patient. Could all of her symptoms be connected? Was I missing the bigger picture? Was there an autoimmune issue or did she have a factitious disorder? Was I feeling this way because I was a third-year medical student on only my third week of rotations taking on a complex patient? Although I knew in my gut a key piece of information was missing, I could not figure out how to unravel this enigma.

I gathered her remaining history and did a complete physical exam, making sure to acknowledge each area of concern on her body. I also discussed potential reasons for her ailments to show her that I was taking her concerns seriously. Once finished, I left the room feeling perplexed.

When I returned with my attending physician to review her history, I was on edge once again and even struggling to breathe as the young woman described her afflictions. We determined which symptoms were a priority and were wrapping up our plan-of-action discussion when my attending asked her, “Do you feel safe at home?”

“I guess. What do you mean by safe?”

The doctor followed with, “Have you ever felt unsafe or experienced violence at home in the past?”

After a moment of thought, the patient revealed, “Well, when I was young, I saw my father beat my sisters. Do you mean something like that? He never beat me, but I hid in the bathroom with my doll and I could see him hit them. I was really scared, but I never told anyone this before. I actually forgot about it all until now.”

I watched a tear roll down her cheek in a moment of silence.

My attending explained, “Sometimes our bodies feel pain from the burden of experiences that impact us mentally. Without knowing, you may have carried this traumatic experience with you over time. You’ve been working so hard all this time to be strong, but now your body may be responding with the different aches and pain you’re having.”

The patient’s eyes reflected a momentous realization — she had finally found a possible explanation of her pains in the wound inflicted on her mind years ago. In that moment, I felt a tangible shift in the energy of that room. My breathing slowed and a feeling of calmness overcame me. Pre-pandemic, I would have instinctively reached out with my hand to comfort her. Instead, the three of us sat at eye-level a few feet away from each other using silence and our body language to convey our support.

When during my medical training would I obtain the intuition to suspect that an adverse childhood event was the true source of her pain? Could I have ever initiated the healing process without revealing this root cause? 

It takes a high level of compassion and empathy to sense the energy exuding from a patient and see the physical signs of a body burdened by mental scars from previous trauma. Being fully present with patients is critical to notice such nuances and a doctor must be in tune with their own mind, body and spirit to recognize when another person is not. As my attending later explained, she recognized the unsettling ambience in the room as a hint to investigate the potential of  underlying trauma. She also emphasized the importance of taking mindful breaths before entering a patient’s room as a means of separating one’s own emotions from that of the patient. 

Whereas I saw a woman with an unusual motivation during a pandemic to overcome health problems, my attending saw a person having to work harder than normal to be strong because she carries the physical and mental toll of her past. The fact that I could feel my patient’s energy screaming something else is wrong! meant that I had sharp instincts, but lacked the experience to act on them. This feeling will serve as an important reminder in the future to listen more deeply with my mind and body to the feelings left unsaid. In addition to adverse childhood events, this is important in identifying a whole host of psychosocial conflicts that patients might be experiencing, including intimate partner violence, human trafficking and abuse that is not often easily revealed in a 15-minute visit. We, as physicians, owe it to our patients to be fully present despite our frustrations and time constraints because doing so can change a life.

In the end, my patient said, “I know I came in with a lot today. Thank you for listening. I never imagined something like that was still affecting me.” With that, I knew the road to healing was, finally, opened for my patient.

Image credit: Chalk-drawn silhouette of a human head (CC BY 2.0) by wuestenigel

Priya Shil Priya Shil (1 Posts)

Contributing Writer

Florida International University Herbert Wertheim College of Medicine

Priya Shil is a third year medical student at Florida International University Herbert Wertheim College of Medicine in Miami, Florida class of 2023. In 2017 she graduated from the University of Florida with a Bachelor of Science in microbiology and cell science. She enjoys singing, painting, and going to the beach in her free time. After graduating medical school, Priya would like to pursue a career in Emergency Medicine.