Sunday, November 11, 2012


     When he was very young my son, Simon, invented the word "chattermouths" to refer to people who talked so much he stopped listening and could only heed the funny way their mouths kept moving up and down without anything coming out.  I realized he was experiencing a form of noise pollution.
     After that, I suggested that we have a day of silence in our household.  No one was allowed to talk.  It might have been interesting, but we couldn't comply for more than a day.  Raising four boys was a noisy task.
     My kids are [mostly] gone now, but there is still too much commotion everywhere, especially cyber-commotion.  The grown-up world of media advertising and overall information flooding (just knowing so much information is out there is enough to drown us with what-ifs that don't even apply to us) is causing our internal systems to crash.
     Have people always chattermouthed so much?  Are we equipped neurologically to handle the ruckus?
    In the clinic, sometimes a patient tells me so much I think we're both going to succumb in the relentless tide of words.  One sentence follows another, and another, with parentheses and asides, down major thoroughfares and alleyways and onto boat ramps and finally into the miles-deep gray-black vastness of the sea.
    "Stop!" I want to shout.  "I can't think!"
     But instead of saying something so rude, I ask myself what the too-much-talking-one is trying to do,  in contradistinction from the patient's conscious motive for coming to the doctor.  What little termagant has pushed to the front of the crowd, grabbed the microphone, and laid claim to the session?  Why has the patient allowed this long-tongued devil to upstage the two of us?
    Maybe the patient is terrified of hearing bad news, and therefore creates an obstacle course of stories and gossip for protection.  Or he may wish to please, skimming everything off the surface of his life for me, the scientist, to scrutinize.  Maybe it's loneliness that triggers the word-waterfall in which we're both drenched.
     Medical training teaches us that a patient will disclose to the doctor the exact diagnosis and the cure, if  the doctor will just listen long enough.
     There is often a moment when I've reached my limit, overwhelmed by stories and seeming trivialities, wondering, "Why won't this patient be quiet so I can figure out what's wrong?"  Then, I go back through the flow of words and catch one that lights up, a Eureka! moment.  It's an unexpected, and a highly irrational way to make a diagnosis, but sometimes it works.
     This happened three weeks ago.  A patient I hardly knew couldn't slow down her flow of words.  She'd been to six different doctors and had a lot to say about what they'd prescribed and what they hadn't done, and how many tests she'd undergone:  CT scans, MRI, ultrasound, blood tests, colon biopsies.  The she started to tell me the story of her life.  On and on she went, asking intermittently for pain medicine to help with the bad bouts of abdominal pain she had every so often, so that I was beginning to wonder if maybe she was a drug-seeker.
     "I was gonna stop going to you doctors for fear y'all are thinking I just want pain pills," she said, reading my mind.  "But my neighbor said, 'Try my doctor, she's good, she'll help you...'-- So that's why I'm here."
     Flattery, I thought.  Typical of people who want pain meds to trade or sell on the streets.  Florida is the premier state for controlled prescriptions.  Last I heard, we were dispensing twenty times more narcotics in Florida than all the other states put together.
     Then I hit the Rewind and Play buttons on my brain's remote control, and heard,  for fear ya'll...for fear ya'll...for fear ya...porphyria--Yikes!  Could she have porphyria?
     Acute Intermittent Porphyria is so rare a doctor is not likely to make more than one correct diagnosis in a lifetime.  It's beongs to a group of hereditary disorders characterized by problems making heme, a blood protein.  As a result, porphyrins, which are precursors for heme, build up, causing neuropathy and bouts of abdominal pain.  The pain can be severe and disabling, and no one quite understands the mechanism by which porphyrins lead to pain, but they interact with bile and other stomach enzymes, which offers a clue.
     The patient took home a kit to collect her urine for twenty-four hours, and two weeks later the results from Quest Lab confirmed the diagnosis:  porphria.  She really did need pain medicine, for times when the porphyria acted up.  Not prescribing pain pills would be cruel.
     The patient wasn't surprised or impressed by my diagnostic acumen.
     "I knew something was wrong," she said.  "You don't have to convince me."
     Recently, an old friend told me that he thinks doctors talk too much, not patients.  We physicians are more impressed with what we know and what we have to say than the patients are.  Most of what doctors say is irrelevant or uninteresting, he said, and not what he wants to know.  The more I think about it, the more I wonder if he's right.
     The real chattermouths may be us, the doctors, not our patients who are want us to leave the enthusiasm and know-it-allness of doctoring behind, so we can listen to them, and they can be heard.
     I know I've got to stop chattermouthing, and hit Replay more often. 

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