Excerpt of How Doctors Think by Jerome Groopman
(Page 1 of 13)
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Anne Dodge had lost count of all the doctors she had seen over the past
fifteen years. She guessed it was close to thirty. Now, two days after
Christmas 2004, on a surprisingly mild morning, she was driving again into
Boston to see yet another physician. Her primary care doctor had opposed
the trip, arguing that Annes problems were so long-standing and so well
defined that this consultation would be useless. But her boyfriend had
stubbornly insisted. Anne told herself the visit would mollify her boyfriend and
she would be back home by midday.
Anne is in her thirties, with sandy brown hair and soft blue eyes.
She grew up in a small town in Massachusetts, one of four sisters. No one
had had an illness like hers. Around age twenty, she found that food did not
agree with her. After a meal, she would feel as if a hand were gripping her
stomach and twisting it. The nausea and pain were so intense that
occasionally she vomited. Her family doctor examined her and found nothing
wrong. He gave her antacids. But the symptoms continued. Anne lost her
appetite and had to force herself to eat; then shed feel sick and quietly
retreat to the bathroom to regurgitate. Her general practitioner suspected
what was wrong, but to be sure he referred her to a psychiatrist, and the
diagnosis was made: anorexia nervosa with bulimia, a disorder marked by
vomiting and an aversion to food. If the condition was not corrected, she
could starve to death.
Over the years, Anne had seen many internists for her primary
care before settling on her current one, a woman whose practice was devoted
to patients with eating disorders. Anne was also evaluated by numerous
specialists: endocrinologists, orthopedists, hematologists, infectious disease
doctors, and, of course, psychologists and psychiatrists. She had been
treated with four different antidepressants and had undergone weekly talk
therapy. Nutritionists closely monitored her daily caloric intake.
But Annes health continued to deteriorate, and the past twelve
months had been the most miserable of her life. Her red blood cell count and
platelets had dropped to perilous levels. A bone marrow biopsy showed very
few developing cells. The two hematologists Anne had consulted attributed
the low blood counts to her nutritional deficiency. Anne also had severe
osteoporosis. One endocrinologist said her bones were like those of a
woman in her eighties, from a lack of vitamin D and calcium. An orthopedist
diagnosed a hairline fracture of the metatarsal bone of her foot. There were
also signs that her immune system was failing; she suffered a series of
infections, including meningitis. She was hospitalized four times in 2004 in a
mental health facility so she could try to gain weight under supervision.
To restore her system, her internist had told Anne to consume
three thousand calories a day, mostly in easily digested carbohydrates like
cereals and pasta. But the more Anne ate, the worse she felt. Not only was
she seized by intense nausea and the urge to vomit, but recently she had
severe intestinal cramps and diarrhea. Her doctor said she had developed
irritable bowel syndrome, a disorder associated with psychological stress. By
December, Annes weight dropped to eighty-two pounds. Although she said
she was forcing down close to three thousand calories, her internist and her
psychiatrist took the steady loss of weight as a sure sign that Anne was not
telling the truth.
That day Anne was seeing Dr. Myron Falchuk, a
gastroenterologist. Falchuk had already gotten her medical records, and her
internist had told him that Annes irritable bowel syndrome was yet another
manifestation of her deteriorating mental health. Falchuk heard in the doctors
recitation of the case the implicit message that his role was to examine
Annes abdomen, which had been poked and prodded many times by many
physicians, and to reassure her that irritable bowel syndrome, while
uncomfortable and annoying, should be treated as the internist had
recommended, with an appropriate diet and tranquilizers.
Copyright © 2007 by Jerome Groopman. Reprinted by permission of
Houghton Mifflin Company.