“Do you think, because I am poor, obscure, plain and little, I am soulless and heartless? You think wrong! – I have as much soul as you, – and full as much heart!
Charlotte Bronte in “Jane Eyre”
Two months ago, I was offered an opportunity to (once again) become a primary care doctor. Or provider, as the insurance companies prefer to address me. I practice internal medicine in Iron County, a bit less than one hundred miles southwest of downtown Saint Louis. Over the next few months I will (again, once again) do my best to share my experiences with you. The following is my first offering.
He was brought in by his father’s girlfriend. She told me that she was his fiancée, but in this part of Missouri this is a very loose term. Two days ago, I saw a couple who had been engaged for thirty-two years. The gentleman also referred to his partner as his fiancée. I don’t know if these people are leery of being judged by the guy from the city; if they feel that I’ll decide that they are primitive and uncivilized because they haven’t made a legal commitment to each other. There’s a lot of that in Iron County: a pervasive sense of isolation from the big town. As if we belonged to different teams that want to beat each other up.
They drove forty miles to see me. Loose change distance in rural areas. But gas prices are up, almost everyone drives gas-guzzling trucks and SUV’s, and you don’t see many shiny new vehicles on the road. It’s a burden to go see the doctor. Which is why a large percentage of people don’t show for their appointments.
He’s in his early twenties. He has insulin-dependent (Type I) diabetes. He suffers from crippling bouts of anxiety and frequent bursts of temper. Of late he has felt worse. He sits in front of me, to my right. His chair is set against the right side of my desk. I notice that he’s slender. He has quite handsome features. A crop of clean black hair sometimes covers his eyes. He does not make eye contact. He’s holding a two-liter bottle of Pepsi, not the diet kind. He swigs from it every few seconds.
How often do you check your blood sugar?
“Once in a while.”
In my experience, this means next to never.
Why do you think that your anxiety’s worse?
“They took away one of my medicines two weeks ago. I’ve felt rotten since. I have trouble sleeping. I have no appetite.”
His father’s fiancée chimes in. It’s obvious that she likes this kid.
“He’s had it rough. We had to take him from his mother’s house. They took his medicine away because his mother was giving him weed to smoke.”
A harrowing tale follows. His twin brother has autism and cannot function by himself, yet he shows flashes of brilliance when he deals with a few very specific things. His uncle is retarded: he also lives with my patient’s mother. My patient is the only member of this household that knows how to handle these two. His mother is a meth addict. She has been in and out of jail for most of this young man’s life. Of late she has been given a chance to make it on her own, but I’m told that the house is dirty: more often than not there is little or no food. Because of his diabetes, his father felt that he needed a more stable environment.
So you feel like you’re needed at your mom’s.
“I’m good with my brother. I can deal with my uncle. I want to help mom. I should be there.”
I know how you feel.
“You don’t know me. You know nothing about me.”
He becomes agitated. His stepmom begins to fret.
“This doctor is trying to help you.”
“He knows nothing. He doesn’t know what it’s like.”
I am overcome by an overwhelming feeling of impotence. He’s right. There is no way that anyone can know what he’s going through except himself. The picture’s not pretty. Insulin shots; special diets; frequent doctor visits; hunger; stifling heat. To be the head of the household at… Who knows when? Was he three when he realized that things would fall apart if he wasn’t there?
I decide that I have to give him some hope. Yet I know that the odds are not good.
Are you good with animals?
I get a faint semblance of a smile.
“We have a dog,” says the fiancée. “He’s very good with him.”
How about horses?
“I like horses.”
Now a real smile.
“He knows how to ride,” says his stepmom.
We talk for a while. As he becomes more engaged I realize that he’s very articulate, considering the limited care and education that he’s had. He also has unusual insight for a young man.
I think that you’re smart. You have a lot of potential. Maybe you can be a horse trainer. Someone who can introduce horses to autistic children. Maybe make a little bit of money to help your family.
“I can do that.”
There is a facility twenty miles away. He has been told that if he shows some interest, the state may help him get some more education. This means a two hour round trip for his stepmom. Twice a day. She has seven other people in her household. What are the chances, I tell myself.
Let me look into some options. I’ll see if I can find some horse people that may give me some ideas.
He seems pleased. No talk of insulin doses today. No scolding him about the Pepsi. I restarted his antidepressant. I told him that there might be a way out.
I stood up as they left. I hugged both of them. I know deep inside that he’s right: nobody knows. The state cuts taxes for the wealthy at the same time that a little bit of help may keep him from drowning. Of course he can sense that nobody knows!
I say good-bye. Another patient walks into the exam room.
Do you know anything about horses? I ask.