The commonest of problems

I am half way through my final year rotation in general practice and am sitting in on an afternoon clinic. The GP summarises the next patient's notes for me.

“Okay, this man is 56. . . .His wife died at home five weeks ago of rectal cancer. . . . He took early retirement. . . . We've got him on some dothiepin [an antidepressant] . . . he seems to be taking it all quite badly.”

As the patient sits down, the doctor asks him what he's been up to over the past week. He sighs and the tears start as he realises that he has been filling his time with nothing, that he has nothing to fill his time with, and that he is drinking more.

“I can't think of anything that's worth doing. Everything's so empty and useless.” He trails off and I start to remember the feelings that I am just starting to put behind me. My own mother's death is distant enough to no longer be a constant preoccupation but recent enough for the emotions to come back at the slightest provocation.

“There are so many little reminders everywhere. I'm okay most of the time and then something happens and I remember.”

My dad calls these “triggers.” He talks of how he must sell the house because it is full of triggers. How even having an argument with me will upset him and remind him of how similar Mum and I were.

“I know I should be filling my time with something but I don't know what. Perhaps I should go back to work. But I can't concentrate. It's like I want to go back and I don't want to go back.”

I remember my own lack of concentration and confidence. That it didn't bother me to begin with but got progressively more frustrating until eventually I was hiding in the library all day to avoid any clinical contact and the acute anxiety it would bring.

“I worry that I'm going to do something stupid.”

Like what? Like take an overdose? When I finally plucked up the courage to ask my GP for some help he gave me a prescription for paroxetine, an antidepressant, and the standard warning about how long it would take to work. As I returned from my first trip to the pharmacy, it occurred to me that if taking one a day for 14 days would make me feel better then perhaps taking 14 in one day would have the same effect—either that or end things once and for all. And I am supposed to be sensible. I am sensible. I am a rational young woman about to qualify in medicine and yet even I (the invincible) can be brought to my knees by grief.

“How long will this go on for?”

For ever, I think. You're five weeks in now and it's still raw and sore. But in five months you'll still have your bad patches. And five years from now, when everybody thinks you must be well and truly over it, you'll still have those tight throat, fighting back tears moments. “The first five years are the worst,” warned Auntie Pat.

“When I'm with my friends it's like I'm wearing a mask. I can be normal and they think I'm fine. But I'm not, I'm just pretending and when I get home I'm me again and I'm scared.” I was able to function perfectly well at a superficial level quite rapidly after it had happened. But it was wrong and I knew I didn't want to live like that. I did because I felt that most people didn't know how to handle me, wanted me to be the same but were scared about how I might have changed.

“This can't be normal, can it? Something's going wrong. What's wrong with me?”

Nothing. Nothing is wrong with you. Nothing was wrong with me. It is just an unknown. The mask that he had mentioned is what everybody must wear when confronted by grief so that nobody realises how bad it is until it happens to them. It's normal to be going through this. It is normal to think how stupid and inhumane it is that people, even your best friends, won't, or can't, talk to you about it.

And after he has dried his eyes and apologised for taking up our time, we have to decide what to do. The doctor can offer to increase the dose of dothiepin, to refer to the practice counsellor, to be available whenever needed. But all these things feel desperately inadequate. What this man needs is time to work through his feelings, a friend and companion who is willing to listen, someone to love him and hold him when it all gets too much, someone or something to take his mind off his preoccupations. He needs the one thing he hasn't got—his wife. Just like my dad needed his wife. Just like I needed my mother.

And once again the frustration of medicine's limitations and humanity's inadequacies hit me and drag me down and I wonder what all the learning is for if I cannot deal with this, the commonest of problems.

Jean Adams, postgraduate student, Newcastle upon Tyne
Email: jeanadams@bigfoot.com


studentBMJ 2001;09:399-442 November ISSN 0966-6494