15 April 2012

Bird's-eye view

I last read The Great Gatsby 7 years ago. For some reason the character I remember best is a minor one: the owl-eyed man. The man is myopic both in his vision (he wears thick glasses) and in his way of thinking. In one of his appearances, the owl-eyed man crashes his car into a ditch and stumbles onto the road. There, he informs passersby that he has crashed his car. He never thinks to mention that the woman who was with him remains trapped in the smoldering wreckage. In my interpretation, the owl-eyed man vividly sees superficial and trifling details but fails to grasp the bigger picture. Wealthy people like Owl Eyes who have vision yet don't see (and The Great Gatsby has many of these characters) are F. Scott Fitzgerald's indictment of high society.

In a similar vein, clinicians make detailed observations and then must integrate them into the larger story. I was reminded of this maxim during our class about how to interview patients.

This week, it was my turn to interview the standardized patient (an actor who convincingly portrays a patient) while two professors and eight of my classmates watched. I showed her to her seat and asked, "What brings you into clinic today?"

"I just want some birth control."

I questioned her extensively about her sexual history.
-When did you last have sex? "Last night."
-Were you using protection? "No."
-Do you have sex with men, women or both? "Both."
-Have you ever been pregnant? "Yes, twice."
-What was the result of those pregnancies? "I got an abortion."

And so on. Although her responses were evasive, the picture that emerged was dramatic. She reported having unprotected sex with more men and women than she could count. It seemed she had been treated for chlamydia. She used several types of illicit drugs frequently.

Her responses set off a mental checklist in my mind:
-she probably needs emergency contraception ("Plan B").
-she needs to be tested for STDs, including HIV.
-she will need a contraceptive that requires little effort (such as Depo-Provera, a one-time injection that offers 3 months of protection).

Midway through my interview, I asked the class for feedback. One of my professors encouraged me to ask broader questions and to take a different tack. And so, I asked the patient "how she keeps herself busy most days" (so as not to presume that she has a job). After a bit of coaxing, she admitted to being a sex worker. Aha. Now the puzzle pieces fell together nicely. Only after more prodding from the professor did I ask another crucial question--whether she ever been tested for HIV. She had tested positive several times, but never saw the point in starting treatment. This was a bombshell.

Although the first part of my interview uncovered important details, I was slow to establish the larger picture, that the actress portrayed a sex worker who was spreading HIV to her clients. Even so, I outdid the owl-eyed man. F. Scott Fitzgerald would be proud.