Melanie was one of the first patients we met when we opened a family medicine teaching unit at the Pointe St. Charles Clinic.
In those days, the Pointe wasn’t the up and coming hipster haven it is now, but rather a struggling working-class area where the major industries had mostly closed.
The clinic had proud roots in community action, having started as a volunteer project of McGill medical students in the sixties. In the 70’s the clinic administration was taken over by an actual Marxist Leninist cell. Recently, when the cadre demanded that the selfless docs undergo that had been working there just too far demanding that they undergo “class re-education.” All the doctors quit. The community rose up and threw out the administration. Into this chaotic environment we came in with a satellite teaching site of McGill.
Melanie was under the care of Caroline, a first-year resident. Caroline was smart, dedicated and kind. She really wanted to help this young woman who aroused a sense of pity in all of us. Melanie was maybe 19 or 20 years old. Thin, pale, she smelled of tobacco and marijuana, hunching when she stood. When she smiled, she put her hand over her mouth to cover her discoloured teeth. Born and bred in the Pointe, she first came to see Caroline, convinced that she had colon cancer.
“What makes you think so?” Caroline asked.
“Well,” said Melanie. “I have cramps in my stomach and I can’t poo, and I heard on TV that if you are tired all the time and have blood in your poop, you could have colon cancer! I think I might be dying!”
Caroline asked Melanie all the screening questions for colon cancer. Melanie had none of what we call red flags: no family history, no weight loss, though she was woefully thin. She’d had some painful stools with blood on them. Caroline examined her and found a fissure.
“You have a torn bum,” she explained to Melanie. “Your poops are so hard that they’ve torn you. So that’s why it hurts when you poop and why you have some blood. What do you eat?”
It turned out that Melanie’s diet was appalling. She survived mostly on chips and coke. She worked in a convenience store in a subway station and had an egg sandwich from their fridge most days for lunch. She didn’t smoke herself, but, “At my house, there is always a carton of Exports and a bag of dope on the table,” she said. “My parents, grandparents, and brothers sit around all day and argue, and roll joints and cigarettes. I don’t like that, so that’s why I go to work. They all make fun of me because I get up early and go. They say why am I wasting my time when I could go on welfare like all of them and just do some under the table work? I don’t want to be a stripper! I’m not sexy! And I get too nervous!”
She was very nervous, sometimes shaking with anxiety, with her shoulders up as if hiding her tiny breasts. Her family gave her no support at all, laughing at her as she went to work, deriding her when she came home on winter evenings.
No one in her family cooked. They lived on dried ramen, Kraft dinner and take-out chicken when their welfare cheques came. Her family was, in fact, lazy, manipulative and mildly criminal. Melanie didn’t fit in. Shaking with anxiety, she was courageously trying to break out of this mindset. Yet she was haunted by fears.
Caroline was trying to help her by managing her symptoms. She worked with her, took her time, introducing her to exotic foods like spinach, oatmeal and oranges. She did carefully selected tests, making sure that Melanie was safe and ruling out probable diseases. She tried to avoid feeding into her conviction that there was something terrible and secretly wrong.
Melanie began shopping for her own food. She met with the nutritionist and ventured into the community cooking class, where she met some new friends. They were mostly kindly elderly ladies who lived alone and new immigrant moms who were adapting to a strange climate. Melanie bought some food and got some second-hand pots from the program. Her stools became softer and her abdominal pain improved.
“I think that I have pneumonia,” said Melanie when she had a cold.
“Or maybe its lung cancer,” she suggested a week later.
“I saw a special on TV. I think I have Lupus.”
“I’m worried that I have AIDS.” she said one day.
“Why do you think that?” asked Caroline.
“I’m cold and tired, and my joints hurt and see here in my neck there is this swollen gland. Doesn’t that mean AIDS or maybe Leukemia?
Caroline examined Melanie, finding only a tiny calcified lymph node, common in people who have ever had strep throat. There were, as expected, no signs of HIV disease or Leukemia or even Lupus. After reassuring Melanie, she asked her, “But Mel, I thought you have never been sexually active?”
“No, no, never,” replied Melanie.
“Have you ever used needles or had a blood transfusion when you were a baby or anything?” asked Caroline.
“Oh no, no, never!” was Melanie’s startled reply.
“Let’s do some blood work,” I advised Caroline. “Even though she has no risk factors for AIDS. I worry that she was sexually abused at some point. Let’s do an STI work-up and some basic blood work and make sure she doesn’t have a thyroid issue.”
“OK,” said Caroline, “But what are we doing about her somatizing? I know we are doing her good and helping her to a healthier lifestyle, but this disease-of-the-week thing is making me crazy. Is there a way to help her with that?”
That day Josiane, the psychologist, was working with us. I turned to her with eyebrows raised, “Any ideas?” I asked.
“Well, you know that somatization, what we used to call hypochondria, is an over-interpretation of normal bodily sensations as being pathological,” replied Josiane. “Maybe you can work with Melanie, so she understands these feelings are just normal stuff and that she isn’t dying each time? Also, have her come back for regular appointments every month. That way she doesn’t need to present as ‘sick’ to get a fix of support.”
Melanie returned a few weeks later to get her blood test results, thankfully all normal. She was complaining of headache.
“Do you think I have a brain tumour?” she asked Caroline.
Caroline questioned her, examined her and carefully explained to her why it was very unlikely that she had a brain tumour.
“You are a very sensitive person,” she explained to Melanie. “You feel normal changes in your body more than most people, and that makes you frightened. Once you are frightened, you start thinking of the worst possible thing it can be and that makes it hurt more.”
“Not a brain tumour?” asked Melanie.
“No,” replied Caroline gently. “This is a spasm of the big muscle going from the top of your head down your neck. We don’t know why, but this muscle tends to spasm when you are so tense. It really hurts!”
Caroline then showed Melanie some neck stretches she could do.
“OK, so not a brain tumour!” The relief was palpable in Melanie’s voice. She felt heard and understood. She felt safe.
Over time, Melanie’s somatizing became less dramatic. The cooking class gave way to a sewing class. She began to have real friends, some of whom also worked. She felt less like she was the weirdo her family told her she was. She looked healthier, stood straighter. Caroline found her a free dental clinic and she had her teeth fixed and cleaned for the first time in her life.
Caroline was also encouraging her to go back to school. Melanie was hesitant, but she did join an adult literacy group. She moved to another store, this time above ground.
One day, when Josiane and I were watching from the other room, Melanie came in for a regular appointment. She was doing so well now that Caroline was seeing her only every three months.
“I saw a show about cancer of the pancreas,” she said as she came in. Josiane and I looked at each other with alarm. “I started to worry about my gas,” she said with a little frown. “But then I realized I was just being super aware of my body working and I relaxed.”
I looked at Josiane. She looked at me. We high-fived each other and laughing, began to do a little victory dance! When Caroline came in, laughing too. “Be careful, she could hear you!”
“You know, Caroline, we won! I really think we won.”
“We won? No, it was Melanie that won,” said Caroline.
So often, when we watch TV, there’s the one-time brilliant diagnosis that sends the patient to the operating room where their entire life is solved! In family medicine, the changes are often slower and more incremental. With Melanie, she was the person who took chances, rose to the challenge. We showed her a path towards better health and supported her journey along it, but she’s the real hero of this story that happened so long ago. I still remember it because of the almost miraculous transformation in the patient — a transformation brought about through the relationship she had with her young doctor and her stubborn courage.