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The Art of Medicine

Doughnuts for breakfast

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: October 2020 - Volume 33 - Issue 10 - p 58
doi: 10.1097/01.JAA.0000697276.92214.44
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This 14-year-old boy has come to the office for his annual physical examination. I recall seeing him once or twice over the course of this past year, always with his mother. Today she sits in one of the two orange chairs by the window. The other chair is vacant. The boy has already assumed his perch on the examination table, head down between his shoulders.

“Come on, it's not that bad,” I say to him with a slight smile. “School's out for summer, and you don't even have to get any shots today!”

“Really?” He looks up momentarily, then drops his head down again.

“How's life?” I ask him.

“Okay,” he says in a muffled voice.

“Look at the doctor when he's talking to you,” his mother says.

The boy lifts his head again. “Okay,” he says in a quiet whisper.

I review the PHQ-9 in the chart. “I see you sleep a lot — tired all the time?”

“He doesn't get to bed until 1 o'clock in the morning,” his mother says. “Too many video games.”

“That right?” I ask.

“I play online with my friends,” he says.

“There's plenty of time for that earlier in the evening,” I say. “How many hours a day would you say you spend playing video games?”

The boy shrugs his shoulders.

“Too many,” his mother says.

“It's summertime. I know it's been hot, but you've got to get outside, do something physical—shoot some hoops, go swimming, ride your bike. Have you got a helmet?”

“Yeah,” he says.

“But he doesn't wear it,” his mother says.

“That so? You've got to wear your helmet. Ever hear of Humpty Dumpty? If you take a spill and break your wrist, we can fix that. It's a lot harder to fix a cracked head.”

The boy remains silent. I proceed with a sequential examination: head, eyes, ears, nose, teeth, throat, heart, and lungs. “Lie down and let me check your belly,” I say.

The boy lies down. Dutifully, I listen, then proceed to percuss the liver and spleen. “What did you have for breakfast this morning?” I ask.

“Doughnuts,” he says.

“Doughnuts?” I say. “How many?”

“Two,” he says. “One chocolate glazed and a powdered cream-filled.”

“I usually make him a good breakfast,” the mother says, “eggs and bacon, pancakes or waffles. But today I didn't feel like cooking.”

“Some days are like that,” I muse.

I ask the boy to come down from the examination table so I can check his spine. I instruct him to extend his arms forward and bend at the waist.

“Today I didn't feel like doing anything,” his mother says.

“It's certainly been hot,” I say, “too hot to cook a big breakfast.”

Her eyes meet mine as I survey the hump of her son's stretched spine.

“My brother died 2 days ago,” the mother says; and suddenly I stiffen, my fingers frozen midway down the boy's back.

I motion for the boy to come up and have a seat. “I'm so sorry,” I say. “How old was he?”

“Forty-two,” she says.

And then, even though I somehow already know the answer, I pose the next question: “What did he die of?”

“Overdose,” she says.

Even though I expected it, the answer still stings.

I look at the mother; I regard her son. There are many things I could say. I could ask about the particulars, I could flesh out the history. How many years had he been using? How did you find out? Did he leave a wife, a family behind? I could use this as a teaching moment for the boy, to send him a message and drive the point home: Stay away from drugs, don't take that first step.

But for right now, just now, I choose to use this moment for a time of silence, a time to take a deep breath, exhale slowly, and honor a shared grief.

Copyright © 2020 American Academy of Physician Assistants