I had this revelation in one of my fluffier requisite classes during my second year of nurse practitioner school when I was required to take the Jung Briggs Myers Personality test. This 72 question exam breaks down your personality into four adjectives. My typology profile defined me as the following: extroverted, intuitive, thinking, judging. This, for whatever it’s worth, is a decent representation I suppose, but I felt skeptical of these results, particularly given there are only 16 possible personalities. What particularly grabbed me was my astronomical judging score of 87%. I mean, 87%? This makes me the Simon Cowell of medicine. So, why then is it important to know that your primary care provider is judging you, aside from increasing your anxiety as you sit in a backless gown, shifting on a papered exam table?
Fear not, I work in pediatrics and won’t be judging you personally (unless you are a prodigious and/or supercool teenager who reads Avidly). I frequently compare my work to that of veterinary medicine, since the diagnosis of pediatric ailments is based almost entirely on examination. And though shrieking children are white noise in my office, I enjoy my job and, as it turns out, the puzzle of diagnosis with a minimal oral history is a challenge that fits nicely with my judginess. I have learned, in a year’s experience as a nurse practitioner, that your body is not as tight a ship for your emotions, your stories, and your ailments as you may have thought.
For example, I have an baby boy with a linear arrangement of red circles running down the center of his chest. Uh oh: your baby boy has a nickel allergy and has developed a reaction to the snaps in his onesie. Or, I have a sociable young girl who has been grabbing at her crotch for a few days. Could it be a UTI? Maybe it’s a yeast infection? Upon examination, you find a wad of colorful foam, which you are quickly informed by her mortified mother, is the inflated remains of a novelty pill that magically turns into a farm animal in water. “I was putting the animals back in the barn,” she says gleefully. Indeed, she had.
On a standard child’s physical, I see normal kid bruises, indicative of backyard exploration and curiosity, like on knees, elbows and shins. But, there are marks that you discover in places less prone to injury from a fall, like the inner thigh or neck, that suggest they are non-accidental. Then there are circular singes on shoulders, or ‘rashes’ in the shape of pliers. Children stutter and become cagey when asked where these marks came from. These are the scary discoveries, the ones you find on routine visits. Nobody brings their child in because of these injuries; you stumble upon them.
Teenagers provide an entirely different challenge. Adolescence induces muteness. Seemingly endless bodies changes and surging hormones result in little motivation from teens towards conversations about whether they are getting enough calcium or if they are sexually active. As a young woman, I make no headway in my attempts to make conversation with teenage boys. Not that I can blame them, what with knowing that there will be an inevitable and medically-necessary inspection and palpation of their junk.
Despite the silence of a teenage exam, reading the non-verbal cues is paramount. My judging begins the second I walk into the room. Is the patient caked with make-up? Do they smell of cigarettes? Do they arrive with a parent or partner or are they here alone? How is their affect? It quickly becomes a dizzying montage of snapshots that you try to string together into a cohesive story.
Psychosomatic complaints add a deceptive layer of complexity to many visits. Abdominal pain is the most common. After all other physical and emergent problems are ruled out, the time comes to read more deeply into the non-verbal cues in the room and consider a mental health diagnosis. You stand at the serving line, ball in hand and serve. “Tell me, how are things at school? How is life at home?” Tears form, stories rush out and you as the nurse practitioner can feel, on a good day, like a champion. Game, set, match.
What then follows is a thorough investigation of the patient’s hands. It is cliché to claim hands as unique (fingerprints, palmar creases, blah blah), but they do hold clues into the patient’s life. I examine nails to see if they are chewed to the quick or if they are dimpled from nutritional deficits. I check their forearms for the foreboding presence of parallel linear wounds and look for whether those wounds are scabbed or scarred. I search for signs of deliberate trauma, like asymmetrical knuckles from untreated fractures resulting from punching walls in anger, or teeth marks on the index and middle fingers from chronic self-gagging.
What is most arduous is that these narratives do not always resolve. I leave one logic puzzle and walk into another one, repeating the cycle every fifteen minutes. A year of experience in the medical world, I find myself thinking back to the sage words of one of my most beloved professors: “Your patients will haunt you”. And they do. Patient vignettes, both comical and terrifying, hit me suddenly at unexpected moments. I now understand why my god-father, an internist of 30+ years, favors romantic comedies over war films at the end of his work day.
Bodies, I have discovered, say a lot on their own accord. The proverbial ‘chip on the shoulder’ is more literal than you may think. Every scar, rash, ache, and anomaly hints at a story. In medicine, it turns out, it actually helps to judge a book by its cover.
Lucy Kahn: Fierce Vaccinator