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More than meets the eye: Lessons in patient cosmography

Maurer, Brian T. PA-C

Journal of the American Academy of PAs: January 2014 - Volume 27 - Issue 1 - p 1–2
doi: 10.1097/01.JAA.0000438544.95956.03
Mindful Practice
Free

Brian T. Maurer has practiced general pediatrics for more than 30 years. As a clinician, he has always gravitated toward the humane aspect in patient care—what he calls the soul of medicine. Over the past decade, Mr. Maurer has explored the illness narrative as a tool to enhance the education of medical students and cultivate an appreciation for the delivery of humane medical care. His first book, Patients Are a Virtue, is a collection of vignettes illustrating what Sir William Osler called “the poetry of the commonplace” in clinical medical practice. Interested readers can find more of the author's writings at his website and blog.

Tanya Gregory, PhD, department editor

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Whilst my physicians by their love are grown Cosmographers, and I their map...

—John Donne in “Hymn to God My God, In My Sickness”

“I can't believe that my daycare called me out of work to come get my daughter just because she had a fever! If this keeps up, I'm going to lose my job.” It doesn't take a seasoned clinician to tag the venom in this young mother's voice.

She stands before me next to where her infant daughter lies on the exam table, fire flying from her green eyes. Dark bangs frame her high cheekbones; a sheer black, sleeveless dress clings to the curves of her torso down to mid-thigh. Except for her face, every inch of exposed skin on her arms and legs is covered with tattoos.

“Do you think you could give me a note to get her back into daycare tomorrow?” she asks. There is a hint of desperation in her words.

“Let me examine your daughter first,” I say, wondering how I am going to deal with this mother's demands and extricate myself from a sticky situation. “How high was the fever?”

“They told me 100 degrees on the phone. That's not really a lot, is it? I mean, come on—they can't deal with a kid who's got a one-degree elevation in temperature?”

“Do you know how they took it?”

“You mean the type of thermometer or where they put it?”

“Both.”

“It's a digital thermometer. I think they took it under the arm. One hundred degrees isn't so high, is it?”

“One hundred degrees axillary is a mild elevation in temperature, usually nothing to get overly excited about in a 6-month-old baby.”

“Thank you!” she says, hands on hips, spewing off some more steam.

I understand the situation completely. Most daycare centers won't house a child with fever on the off chance that she might be harboring a contagious disease. They don't want to risk exposing other children at the center to illness. On the other hand, the parent pays for the care, fully expecting that the center will watch the child during the work day. These days many young mothers need to work to make ends meet, even though they end up paying a considerable portion of their earnings to child care.

Only one thing nags at me in this particular case: the mother's tattoos. Frankly, I can't imagine what would possess anyone to pay enormous sums of money to have every square inch of body surface area covered in tattoo art.

Momentarily, I step back and check my attitude. As a clinician, I am morally bound to accept the patient wherever she might be and render appropriate care. Somewhat ashamed of myself, I shake off my prejudice and proceed to examine this woman's little girl.

As I listen to the child's chest and palpate her belly, I think back to a story shared by a dermatologist colleague—someone I respect as a practitioner of humane medicine, a doctor who has been in the business for more than 30 years.

He once told me that he had heard a fellow dermatologist comment that most young people with tattoos were dropouts, unemployed, drug dealers, or prostitutes. My colleague decided to do an informal survey of tattooed patients in his practice. As an aside at each visit, he would take time to question patients with tattoos about why they had elected to get it and the circumstances behind acquiring it.

One young man, a fellow in his late 20s, sported an orchid tattoo on his shoulder. After he finished addressing this young man's chief complaint, my colleague asked his patient what had prompted him to get the tattoo.

“Well, doc,” the fellow explained, “it's like this. Orchids were my girlfriend's favorite flower; she loved them. So I had it done in memory of her.”

“In memory of her? What happened?”

“She died in an automobile accident—killed by a drunk driver.”

“I'm so sorry to hear that.”

“Yeah, it was bad. Only here's the catch, doc,” he said. “That drunk driver was me. I was behind the wheel of the car that night; she was riding next to me in the passenger seat. I took a curve way too fast, flew off the road sideways into a tree. I walked away from the accident; she died. Sometime afterwards I dried out in rehab, got the tattoo; haven't touched a drop of the sauce since.

“That tattoo keeps me straight,” he said, gently patting his shoulder. “I've always got her with me.”

I finish examining my little patient, then turn to her mother. “It looks like your daughter is coming down with a mild cold,” I explain. “She's probably somewhat contagious; but if her fever is down by tomorrow, she can most likely return to daycare.”

“Could you—”

“I'll give you a note,” I tell her, scratching a few lines on our office letterhead.

“Thanks,” she beams. “I thought she was okay.”

I watch this mother walk down the hallway carrying her little girl on her hip. Maybe someday I'll broach the subject of those myriad tattoos with her. Until then, I'll consider her to be an ordinary patient whose life is undoubtedly filled with ups and downs—joys and heartaches—just like my own.

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© 2014 American Academy of Physician Assistants.