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The Art of Medicine

Smiling eyes

Sweeney, Cameron Young MMS, PA-C

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JAAPA 36(3):p 50, March 2023. | DOI: 10.1097/01.JAA.0000918784.57066.4f
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She has a family history of breast cancer but has not had cancer herself. She has not returned to her primary care provider because she is uncomfortable with him performing the breast examination. She had been coming to my supervising physician for years before our cancer institute launched a high-risk clinic for women with a family history like hers, and she prefers to continue being seen in our oncology office. We follow her with mammograms and annual clinical examinations.

My supervising physician retired earlier this year, so I meet this patient for the first time. She tells me how much she misses the physician. The patient recalls “her warm hands and blonde hair” and says how I remind her of the physician, despite the fact that I am 20 years younger and wearing a mask that obscures most of my face.

After exchanging initial pleasantries, I ask about any updates to her family history. She quickly responds that she has no family left, but when I ask if she has siblings or children, she readily reports that she has a daughter and two grandchildren. It's funny how many people think that family history refers only to the generations that preceded them. I remind her that her daughter is her blood relative, too.

“My daughter is healthy. And the grandchildren, well, they're off living their own lives. I never see them, it's like we're hardly even related.”

The patient tells me how tired she is. She's moving out of her house of 25 years, downsizing to a place with a first-floor master bedroom, because she doesn't want to negotiate stairs on a daily basis, now that she is in her 70s. I commiserate about the strain of moving and reassure her that eventually she will feel settled again. She sounds doubtful. “I lost my husband 9 months ago. We were married for 42 years, and nothing is the same without him.”

I suggest referral to a grief counselor, but she declines, insisting that she “just has to get through this.” She adds, “Talking about it doesn't help. It doesn't change the fact that he's gone.”

“It doesn't change it.” I counter, “But it can help you process your feelings about the loss.”

She considers my words, hesitates, then volunteers that she finds comfort in her strong faith.

As I review her vital signs, she informs me that she has lost 35 lb. She likes the way her clothes fit and insists that she eats three meals a day. “I think it's just because of the stress.”

We discuss the association of adipose tissue with estrogen and hormone receptor positive breast cancer. I am skeptical that she has been eating enough and remind her of the importance of adequate protein combined with a balanced mix of vegetables, fruits, and healthful fats. “I want you to lose weight for the right reasons, not because you aren't eating.”

Before I can continue my review of systems, she blurts out, “He was my soulmate,” referring to her husband. “We were high school sweethearts. We were together forever! We completed each other's sentences; we knew each other's thoughts without speaking. But the worst thing....” Her voice trails off. She starts again, “I can stay busy during the day. I go on day trips with friends. We go shopping, or sightseeing, or out to eat. I talk to friends every day. But the nights... the nights when you crawl up those stairs and get into that big empty bed, alone. That's what I can't bear. That's when the loneliness is the worst.”

She looks past her toes and whispers, “I didn't expect to bring that up.”

As I finish the physical examination and stand before my patient, I think about a phone call with a friend last night. He told me that there is something about my eyes that is warm and comforting and invites people to tell me what they are feeling. I recall laughing it off, insisting that it's just my job to put others at ease.

Now, despite my N95 duckbill mask and plastic safety glasses, the patient says softly, “You have pretty eyes.” She looks at me and pauses. “They sparkle and smile.”

“Thank you for such a nice compliment!” I smile under the mask and feel the corners of my eyes crinkle.

I push in my stool with my foot and reach for my clipboard. The patient is seated on the edge of the examination table. As I turn to go, she reaches out her hand. I clasp it in both of mine and look into her eyes.

The work we do is so much more than the history, physical examination, and review of laboratory tests and screening or diagnostic studies. The people we care for are vulnerable, sometimes clad only in a blue paper cape. We clinicians are privileged to care for them, often with little more than a warm gaze and a willing ear to offer some comfort for whatever may trouble them, even if it's not on the problem list.

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