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The doorknob questions

The doorknob question is the bane of family doctors’ existence. Very often you have gone through an entire interview dealing with trivialities, the whole time a growing sense of unease coming over you as you feel something hovering at the edge of the conversation. “Anything else?” you question. “Anything worrying you?”

You let the patient go, writing the prescription or giving the advice. After all, there are other patients waiting. Just as the patient rises to leave, often with their hand on the doorknob, they turn around and ask the question, or bring up the topic that has been the real reason for the visit. Now you have two choices. You do the rational thing, what we teach our students to do.  You should say, “That’s very important, we’ll talk about it next time.” Or you recognize the vicissitudes of real life, blow your schedule and deal with the patient’s agenda, at least a little.

Usually these are the most difficult, the most embarrassing and the saddest questions that arise. Incest, infidelity and suicide are common doorknob topics. One of my strongest memories of a doorknob question was when a sixty year old patient of mine, after an entire interview of me going “anything else,” turned at the door and said, “Doctor Perle, how can you be sure that a child is yours?”  I defy anyone to say “I’ll see you next week” after a question like that!

This week, Arthur came in. Arthur was in bad shape. He has been in very bad shape for a long time now. Severely depressed, he drags himself through the day on massive doses of anti-depressants, keeping himself alive by force of will. “I couldn’t do it to them, but mostly, I just wish I was dead. My kids have been through enough, since their brother died,” he says. He never speaks of his stepson’s violent mode of death as suicide.

My heart melts for him. He is trying really hard but his life has completely fallen apart.

I met Arthur at what was probably the happiest time of his life. He had finally won he heart of the girl he had loved since high school. He had been the nice “best friend” watching the girl he loved fall for a dangerous, sexy, and ultimately abusive man.  He stood by as a friend as she extricated herself from her abusive marriage and, as a single mother of two small boys, went back to school to become a social worker.  Finally Sylvie realized that the shy, sad eyed man who had been her buddy for so long meant more to her than that.  They married and I delivered their two little girls. They seemed happy and content.

Sylvie sent me her boss, Raoul, as a patient when he married and his wife got pregnant. Raoul and Patricia were an odd couple. Patricia was much younger than her urbane and sophisticated husband.  The couple seemed to have little in common and secretly I doubted that this relationship would last. While there was obvious passion between them there did not seem to be any liking or kindness. They just weren’t that nice to each other.

A few years later Arthur and Sylvie moved to small town Ontario to take care of Sylvie’s grandmother. When they moved back to the city a few years after that, things just seemed to have fallen apart. Arthur had had a depression while they were in Ontario. He had not adjusted to small town life. Sylvie was incredibly stressed, with terrible migraines. The contentment between them seemed strained if not gone. “At least I get to work with Raoul again,” Sylvie said. “He really understands who I am and what I need.”

Over the next few years, from my episodic perspective as the family doctor, I watched things unfold as if they were principals in a terrible soap opera.  Like the movie, Rashomen, by Kurosawa, I heard the same story of depression, infidelity, betrayal, and manipulation from four different perspectives. The worst of the matter was that Sylvie’s oldest son started acting out.  He became angry, started using drugs, being violent. When Youth Protection services came in and removed her son from their home and put him in a group home it broke Sylvie’s heart.

Then it happened. Sylvie’s son was found dead on the train tracks. It was not clear whether he had been killed playing chicken with the train or whether this was a suicide.  Arthur went out the night after he died and walked the tracks. He found the spot, the remains of blood and brains that had been the son of his heart.

Since then he has been a mess. Three years have passed, two admissions to the psychiatry ward, an abortive move to Toronto. Still he is hanging in.

“You are doing everything you can,” I said, tears in my eyes, as they often are when I meet with Arthur.  “You are doing therapy, taking your meds, doing exercise, trying to take care of the kids, you just have to be patient, hang on.”  I felt really impotent; I knew there was really nothing I could do for him. “I’ll do what I can for you,” I said. “All I can do is walk along this path with you.”

Arthur stood up and walked to the door. “I really appreciate it, Perle.” He turned at the door with his hand on the knob, “Oh, by the way…”

I felt a sudden rush of panic. Oh no, a doorknob question! What could be harder, more stressful, more depressing than what we had been discussing? I braced myself mentally, preparing for the worst. “What’s the problem?” I asked.

“I have a bump on my foot that makes it really hard to walk,” he said.

When Arthur removed his sock, I could see he had a huge wart on the ball of his foot. It was about as big as a loonie, with deep roots and a horny piled surface. “How long have you had this mother?” I queried.

“Oh a long time,” Arthur said. “I haven’t really been paying attention for so long, but now it’s really hard to walk.”

Breathing a huge sigh of relief, I happily took his foot onto my lap. Using a scalpel blade, I peeled the wart down so that it wouldn’t hurt, gave him instructions and arranged for him to come back for a liquid nitrogen treatment. Suddenly I felt good, I was so happy to have something simple, physical and immediate to offer him, to see that I could help him in a meaningful way. I had made him better. I like that.

“Oh that’s great,” said Arthur, putting weight on his foot. “I feel a lot better.”

“Me too,” I said as I walked him out.