Doctors, Harp Lies, and Trump Talk

I first heard the phrase “harp lie” on Starlee Kine’s tragically short-lived podcast, "Mystery Show." “If I tell you I’m a great piano player or a great singer, you can pretty easily figure out if I’m lying,” Kine explained. “It’s easy to find a piano, even easier to just ask me to sing something. But if I tell you I’m a great harp player, what are the chances you’ll be able to find a harp to see if I’m telling the truth? So I call those kinds of lies, the ones that you can never prove one way or the other, ‘harp lies.’” Am I the only doctor who’d hear such a thing on a podcast and reflexively think of talking to patients? This past weekend, as the physician on-call, I fielded a number of phone calls that yielded some version of “harp lying” on my end. Someone wondered if her single episode of vomiting could be attributed to the antibiotic she’d been taking for a urinary tract infection. Sure, I replied. Someone else had five minutes of tingling in his fingers and toes, only on the right side, that resolved spontaneously. Had he slept on the right side the night before? I asked. He had, and he subsequently agreed to sleep on the left side the following night. Another patient, with a debilitating migraine, wanted to know if she could take an Excedrin Migraine because it was the only thing that helped with such severe headaches. Her regular nephrologist had told her to avoid the medication except in extreme situations. I told her this episode seemed to count as “extreme” and a one-time dose was unlikely to do any harm to her kidneys. Of course, these weren’t exactly harp lies, because my suggestions would be tested out over the next few hours or days. If the first patient vomited again, if the second patient ended up having some sort of neurologic event, and if the third patient’s kidneys didn’t tolerate the Excedrin, then I’d be facing the medical equivalent of being forced to give a harp performance. On the other hand, if the patients all fared well, as I suspected they would, then I could continue to pose as a harpist extraordinaire even if their recoveries had little to do with the medical advice I’d relayed over the phone. Bernard Lown, the Nobel prize-winning cardiologist, wrote in his memoir, The Lost Art of Healing, “At times I have gone so far as to guarantee recovery when the scientific basis for a cure was tenuous or nonexistent.” Some doctors might call this bluffing. Others would consider this a version of the placebo effect. Patients, though, would probably read Lown’s confession as a variant of harp lying. But what, exactly, is wrong with harp lying if it’s done with the intention of making a patient feel better? Especially if it works. Readers of Danielle Ofri’s latest book, What Patients Say, What Doctors Hear, should recognize Lown’s guarantee—and, to some extent, my answers as the on-call physician—as a form of reassurance, one of the strongest tools a doctor can wield in his or her practice. Ofri, an internist at Bellevue Medical Center, recognizes the crucial role of narrative in the medical encounter, yet also recognizes that “the story the patient tells and the story the doctor hears are often not the same thing.” She spends most of her new book trying to tease out why this disconnect occurs and offering up strategies for physicians on how they can repair the communication process. Reassurance emerges as one of these strategies—not necessarily guaranteeing patients that their outcome will be good (as Lown was wont to do), but simply communicating to patients that their doctors will be present, available, and invested throughout the story. “There is clearly an asymmetry between the doctor and the patient—doctors endlessly reciting the facts of the disease and patients with a store of crucial information that never gets on the table,” Ofri writes. This asymmetry, she concludes, is due mostly to an underappreciation, on both sides, of the “crucial role of the story.” In her view, every patient has a story to tell, and the role of the medical encounter (whether it’s a doctor-patient phone call, a regularly scheduled clinic visit, or an unanticipated encounter in the hospital emergency room) is to craft this story. Both sides—doctors and patients—must participate in the telling of these stories for them to reach their proper conclusions (i.e. healthy patient outcomes). Ofri views the doctor and patient as “co-narrators” working together “to draw out, enhance, and shape the patient’s story.” This might sound like soft science but the results are tangible—patients who feel their doctors understand their stories do better, not just on patient satisfaction surveys but in hard outcomes like rates of cardiovascular events and overall survival. The time a doctor spends listening to his or her patient, the effort made to truly understand what the patient is saying, may have more of an impact on how the patient feels than any intervention prescribed by the doctor. In discussing the well-known placebo effect in medical settings, Ofri suggests that the same results could be elicited even without a fake pill. “Wise doctors and nurses already know…that their ‘everything else’—respect, attention, comfort, empathy, communication, touch—often forms the lion’s share of medical care, no deception required.” I assume this “no deception required” would apply to harp lies, too, but I’m not sure. Recently, at least in the medical circles I frequent, a short research letter made some big waves. In the December 27, 2016 issue of the Journal of the American Medical Association, Samuel Volchenboum and colleagues at University of Chicago reported on the risk that hospitalized patients face when another patient on their unit experiences a critical illness event. In other words, if a patient in hospital room 1102 suffers a cardiac arrest, how does that affect the patient in hospital rooms 1103, 1104, or 1105? Over a five-year period (2009-2013) covering nearly 84,000 admitted patients, those neighboring patients were shown to have a significantly increased risk for similar critical illness events (defined as either a cardiac arrest or transfer to the intensive care unit) compared with the average hospitalized patient. Exposure to one critical event increased the likelihood that another patient on the same hospital floor would experience a similar event by 18 percent; exposure to two such critical events within a six-hour window raised that excess risk to 53 percent. Part of the reason this research letter struck a chord with so many of the physicians I work with is that it confirmed something we’d observed over and over again about the flow of illness in hospital settings. Some use the term “black cloud” to describe those days when everything goes wrong. Others invoke Murphy’s law. One of my co-residents, years ago, used to lament “The badness is contagious!” during overnight calls when patient after patient decompensated. Beyond confirming our own observations, though, this letter also forced us to consider why this “neighborhood effect” occurs. The letter’s authors suggested that a diversion of resources to the sentinel critically ill patient results in caregivers being less attentive to the other patients on the same ward. I think this answer is true but far more nuanced than it appears on first inspection. The doctors and nurses responding to a patient who’s crashing are not just physically less present for the other patients on the floor, but also emotionally unavailable for these patients. In What Patients Say, What Doctors Hear, Ofri describes why she still puts so much stock in the physical exam. She’s not particularly invested in what she hears with her stethoscope or elicits with her reflex hammer. Instead, she’s eager to delve into the patient’s story without the burden of a computer sitting directly in front of her face. [T]hen the doctor and patient move to the exam table and everything changes. This is often the first moment that we can talk directly, without the impediment of technology. We are physically close to each other, actually touching. This is intimacy, albeit of the nonromantic type, but an intimacy nonetheless…It is a refuge from the intrusion of technology, the intrusion of multitasking, the intrusion of assumptions and biases. It is a moment of only touching and talking. In the medical world—as in the world at large—there are precious few moments of just touching and talking. In the physical exam, she’s found an opportunity to be truly present for another human being at his or her level, akin to when parents put away their smart phones and get down on the floor to play with their children. This reassurance—the confirmation to the patient that he or she is not alone—is what patients want from their doctors, especially when they’re most frightened. Ofri’s repositioning of the physical exam as simply an opportunity to be physically close to patients offers, I think, the more nuanced explanation we need for the “neighborhood effect” described by Volchenboum’s group. Yes, patients are more prone to adverse outcomes when their doctors and nurses are preoccupied with other patients, but these critical illness events are not solely due to lack of attention. Patients need reassurance, and that kind of medicine can only be delivered in person via touching and talking. “Reassurance that you are not in imminent danger, just by itself, can go a long way towards easing pain,” Ofri writes, and “is a crucial part of the ‘everything else’ that doctors and nurses do that decreases pain and discomfort.” The patients in hospital rooms 1103, 1104, and 1105 may simply need a doctor or nurse to enter the room, pat their shoulder, listen to their concerns, and then reassure them that they’re not going to suffer the same fate as the patient in hospital room 1102. In this light, as the on-call physician, my “harp lies” were merely verbal forms of reassurance—that I’d heard their stories, that I thought they’d be okay, and that I’d be easily reachable again if they weren’t. This role of the reassuring doctor, I can’t help but think, is particularly critical in our current political climate. Until recently, politics never came up in my clinic. Since November, however, it’s now the exception rather than the norm for a clinic visit to pass without at least one exchange about, to quote a recent patient, “how scary things are.” On one afternoon, I saw four consecutive patients with no history of hypertension who all posted blood pressure recordings above standard values. Each blamed our recent banter about Donald Trump for their pressure being elevated, citing either anger or anxiety or depression or some combination of these feelings. It seemed that we’d stumbled upon a new form of white coat hypertension, in which blood pressure was rising not in response to being in a doctor’s office but rather to having a discussion about Trump in that doctor’s office. The difference between the conventional form of white coat hypertension and “Trump talk hypertension,” I worry, is that my patients continue these political conversations and tend these same emotions outside my office, when no doctors are around. How bad is Trump for their health, I wonder, and is there anything I can do to help? Toward the end of What Patients Say, What Doctors Hear, Ofri compares the art of medical conversations to improvisation comedy. It’s an analogy I’d never heard before that, upon reflection, makes absolute sense. “You are thrown on stage with a complete stranger who can toss out an opening maneuver on any topic, in any key, in any language, from any one of a million locations beyond left field,” Ofri writes, “and you need to step right in, without any hesitation, as if you had studied that exact script only moments before and were just waiting for that specific cue to begin.” That afternoon with the four newly hypertensive patients, in this light, represented a failure on my part to keep the conversation, the improv act, moving in the right direction. I should have reassured those patients that our country will be fine, that the benefits and rights and privileges they hold dear will be secure, even if that kind of response was, at its essence, a harp lie. That’s what I’m trying to do now when my patients discuss Trump. I have a rehearsed answer for them. I use my gentlest voice. I often save the message until we’re at the exam table, my hand on their shoulders, about to take a blood pressure. “I think we’ll be okay,” I say. “One of the silver linings of this election for me is seeing how impassioned the fight has been to preserve our freedoms. I think we’ll win in the end.” I pause for a moment before adding, “We have to.” And then I start inflating the blood pressure cuff.

The Cruelest Joke: Laughing Through Tragedy

1. There are certain conversations a doctor should have with a patient face-to-face. Telling a young man that his kidneys had failed and he’d need to start dialysis was an example of such a conversation. I’d seen him that morning, and both of us had anticipated that the bloodwork drawn just after his appointment would be bad. I’d patted him on the shoulder as he left my office and headed down to our hospital’s lab. “I’ll call you this afternoon with the results,” I’d promised, and now I was making good on that promise. “Are you serious?” was all he could muster on his end. He asked me the question three or four more times. I answered yes each time. Then I listened to him cry for what seemed like an eternity but was actually just over one minute, because my office phone runs a timer for every call I make. I gave him instructions on where to go for placement of a dialysis catheter. I told him we’d start the treatments as soon as the catheter was in. At the end of the call, I said, “I’m sorry this has happened,” and he said, “Yeah, me too.” After hanging up, I reached into my shirt pocket for my earbuds, turned on my iPhone, opened the app for Spotify, and pulled up Mitch Hedberg’s Mitch All Together. “I can’t tell you what hotel I’m staying at,” Hedberg says on the first track, “but there are two trees involved.” I started to smile. “They said, let’s call this hotel ‘Something Tree.’ So they had a meeting. It was quite short. How about ‘A Tree?’ No. ‘Double Tree?’ Hell yeah! Meeting adjourned!” I started to laugh. “I had my heart set on Quadruple Tree.  Well, we were almost there!” I smiled and laughed and rubbed at my eyes. 2. I’m always listening to something on my iPhone. Late at night, after the kids have gone to bed, I pull up a sports-themed podcast while washing the dishes and making their lunches for the next day. In the morning, I soundtrack my walk to the train with a shuffle of the 200+ songs that currently populate my (creatively titled) “good songs” playlist. I like to listen to The Microphones when I’m walking in the rain, because I imagine every Microphones song was created during a storm. In the winter, I pass an hour shoveling snow with "WTF" or "This American Life" episodes. A few weeks ago, I heard a comic on "WTF" complain to Marc Maron about some of his old albums that are available on Spotify. Until then, I was unaware that Spotify had comedy albums. Since then, I have almost exclusively listened to stand-up comedy on the app. And, to be more specific, I have used comedy albums on that app as my go-to listening for the commute home from work. For me, the listening choices I make for that commute home are prime-time programming. It’s the most important listening decision I make, because I’m exhausted and need to recharge before I get home. Some days I’m physically exhausted; on all days I’m emotionally exhausted. As a doctor who specializes in the rarest (read, most severe) forms of kidney disease, I’m often leaving the hospital and heading home just minutes after telling someone he can no longer rely on his kidneys. Forty minutes later, when I give my kids a good-evening hug and kiss, I need to feel completely removed from the diseases I’ve just left behind. I’ve tried every kind of listening experience to block out the hospital and all its sickness during those commutes home: Frank Ocean is good, for example. Okkervil River’s Black Sheep Boy is a perfect antidote. On the other hand, The New Yorker’s fiction podcast is almost impossible to follow if you’re stressed, and I’d say the same for trying to get into any sort of new music unless it’s from Radiohead or Kanye West. But nothing, in my experience, has come close to the escapism of listening to Amy Schumer joke about catching her boyfriend masturbating (“Does it owe you money? What’s going on? He never chokes me like that!”) or John Mulaney tell the story of playing Tom Jones’s “What’s New Pussycat?” 21 consecutive times on a local diner’s jukebox. 3. “It’s weird because with humor, the equation is tragedy plus time equals comedy,” Tig Notaro says on “Hello, I Have Cancer,” the first track of her 2013 album, Live. “I am just at tragedy right now. That’s just where I am in the equation.” And that’s pretty much where I am in the equation, too, when I leave my office, head for the train, and open up that Tig Notaro album. I’m still in the realm of tragedy, but I need to escape as fast as I can via jokes. I’ve never stopped to reflect on whether this behavior is appropriate until last month, when I read Emily Nussbaum’s New Yorker essay “How Jokes Won the Election,” and in particular her dissection of Donald Trump’s “locker room joke” about grabbing women by the pussy: I saw the Access Hollywood tape, the one that was supposed to wreck Trump’s career, but which transformed, within days, on every side, into more fodder for jokes: a chance to say 'pussy' out loud at work; the 'Pussy Grabs Back' shirt I wore to the polls. In the tape, Billy Bush and Trump bond like the guys at McCann Erickson, but it’s when they step out of the bus to see the actress Arianne Zucker that the real drama happens. Their voices change, go silky and sly, and suddenly you could see the problem so clearly: when you’re the subject of the joke, you can’t be in on it. Nussbaum appears to be making the case for sobriety over humor in the face of such awfulness. It’s not an easy case for her to make either, she admits. The essay opens with a proclamation of how much she loves jokes (“dirty jokes, bad jokes, rude jokes, jokes that cut through bullshit and explode pomposity”) and her discovery, as a Jewish child watching Mel Brooks movies “in a house full of Holocaust books,” of how well-told jokes could empower the oppressed. “But by 2016 the wheel had spun hard the other way,” she continues, pointing out all the jokes that Trump and the hateful “army of anonymous dirty-joke dispensers who helped put him in office” promulgated before and after November’s disastrous election. Those of us diametrically opposed to this man and his army were also playing with fire, misusing humor as a defense mechanism, a form of denial, a way of avoiding talking about important subjects. It’s probably not a coincidence that I jumped headfirst into comedy albums in November, after the locker room joker was elected president. It’s cathartic to hear David Cross rip Donald Trump to shreds on his most recent album. Just as it’s cathartic to listen to Louis C.K. make fun of himself for being so out of shape. Just as it’s cathartic to escape in Mitch Hedberg jokes instead of thinking about the sick person I just spoke to on the phone. But the laughter doesn’t change anything. Donald Trump is our president, Louis will always be fat, and that patient I just spoke to will probably die much younger than he should. 4. The question I need to ask -- the question I think Nussbaum wants all of us to ask as we giggle away our sadness and fear -- is who are the subjects of these jokes I’m enjoying. When I leave my office and all the illness contained within its walls to catch a train home, when I listen to Sarah Silverman or Patton Oswalt or Aziz Ansari, am I just laughing at some jokes? Or am I laughing, in a way, at my patients and their suffering? They’re clearly not in on the joke, and I so clearly want to be in on the joke. I want to be happy, instantaneously, and that desire may not be fair to the patients who need me. In the age of the Internet, we have instant access to jokes. If I can’t find something funny on Spotify, I can find a great standup routine on YouTube. Or I can scroll through Twitter or Facebook, which offer up a daily round of humorous memes from both professional and extremely amateur comedians. Nussbaum sounds a note of caution about this access: Online, jokes were powerful accelerants for lies -- a tweet was the size of a one-liner, a “dank meme” carried farther than any op-ed, and the distinction between a Nazi and someone pretending to be a Nazi for 'lulz' had become a blur. Ads looked like news and so did propaganda and so did actual comedy, on both the right and the left -- and every combination of the four was labelled “satire.” The zeitgeist of 2017, at least in the circles I frequent, is impassioned resistance to the new regime on the one hand, balanced by an equally passionate search to laugh in the face of all this craziness. The Women’s March, as Alexandra Schwartz wrote online for The New Yorker, “in addition to being forceful, moving, and, yes, huge, was funny. Actually, it was hilarious, a vindication of the humor of women performed on a stage that stretched the whole world wide.” But we’re “just at tragedy right now,” as Tig Notaro said. There hasn’t been any time, and the immediacy of today’s media removes any possibility for time. In other words, as a citizen, I don’t have the luxury to wait and see how my country will survive the next four years, just like I don’t have the luxury, as a doctor, to wait and see how a very sick young man’s kidneys will fare. I need to act today. Should I be allowed to laugh at some point during these actions? This question isn’t just taken up by writers for The New Yorker, either. The title track of Father John Misty’s forthcoming album, Pure Comedy, was released the same week as Nussbaum’s essay, with an accompanying video that uses footage of Trump’s inauguration and Obama’s departure, alongside images of parents bathing their kids, a man snuggling with a lion, churchgoers swaying their arms in sync, protestors yelling at each other, and, of course, Pepe the frog (of White Nationalist meme fame), Kanye West, and wrestler John Cena. In an essay released at the time of the song and video, Josh Tillman (a.k.a. Father John Misty) issued a lengthy (nearly 2,000 words) discussion of his forthcoming album’s exploration of the “cruel joke” that is human existence. It’s hard to tell how serious he’s being in any of this -- the song, the video, the essay -- although I think he’s utterly sincere (and correct) when he ends that essay by saying, “The joke is that the best we can do is keep on keeping on, which we’ve proven ourselves pathologically adept at.” Or when he ends the album’s title track with a similar message, “I hate to say it, but each other’s all we got.” And April brings us The Last Laugh, a documentary about Holocaust jokes that defends the role of laughing in the face of the worst situations. In the movie’s trailer, Mel Brooks says, "Comics have to tell us who we are, where we are, even if it's in bad taste." Unfortunately, I have to admit that Trump, for some portion of this country, fits Brooks’s description of a “comic.” But so, too, does Father John Misty, and all the women marching across this country with signs making fun of Trump’s tiny, pussy-grabbing hands. And, I think, so do I. It’s dark outside when I ride home, so the train’s windows reflect my image. I see a doctor clinging to his earbuds, biting his lip, then grinning, then laughing as Mitch Hedberg calms his nerves. I should be with my patients, trying to calm their nerves, but I need to get home. That’s who I am and where I am, even if it’s in bad taste. Image Credit: LPW.

What Do You Think Is Going on? Wendy Walters’s ‘Multiply/Divide’

1. There’s a truism in medicine that’s not entirely true, but it’s important for doctors to think it’s true. This truism goes something like: “90 percent of all diagnoses can be made based only on what a patient tells you.” I’ve heard some minor variations of this truism in my 16 years as a medical student, resident, fellow, and attending physician -- sometimes the percentage dips to 80 percent; sometimes the 90 percent diagnostic rate requires both the patient’s history and physical exam -- but the underlying message remains consistent and unwavering. The patients will tell you what’s wrong with them if you just pay attention to the stories they are telling. In academic hospitals, teaching physicians (like me) throw around this 90 percent statistic to encourage old-fashioned doctoring skills and make students less reliant on the relatively modern luxuries of lab tests and imaging studies that can be ordered with a click of a mouse. Reading Wendy Walters’s first book of prose, Multiply/Divide, made me think of this truism. Walters’s three previous books were collections of poetry, and, perhaps not surprisingly, her first formal venture into prose obsesses over how we construct stories. I still believe that most patients can self-diagnose their illnesses (or lack thereof), which is why I always end my patient interviews with the question “So, what do you think is going on?” if the patient hasn’t already volunteered his or her own theories. I believe less and less, however, that the stories patients tell their doctors are accurate reconstructions. The patients, in recounting what doctor notes call “the history of present illness,” are picking and choosing the salient elements of their story: the plot points, the clues, the signs and symptoms that would be derided in a fiction workshop as too obvious examples of foreshadowing. The patients are telling a story that ends in the diagnosis they’ve made on their own. In other words, the patient sitting across the desk from me, answering the question “What brings you to the office today?”, is real-time drafting a personal essay, and almost certainly doing so without a clear distinction of what’s exactly fact and what’s a little bit fiction. 2. I spent way too much time reading and rereading the three-page introductory notes that Walters provides for Multiply/Divide. In this preamble, she labels the 13 pieces that compose the book as fiction, non-fiction, and lyric essay, even though she acknowledges that “the border between nonfiction and fiction -- while seemingly clear as black and white -- is often porous enough to render the distinction irrelevant.” Before, or more often, in the midst of reading an essay (for convenience, I will label all the works in this book as essays, partly because I wish they were all labeled as such), I’d flip back to that introduction and peak at what classification Walters gave it. And just as often I became disappointed -- disappointed in myself for feeling the need to seek out a category, and disappointed in the essay that I was reading for being so apparently easy to classify. I’m not entirely sure what distinguishes an essay from a story. If pressed, I’d crib from the Supreme Court’s line about pornography -- “I know it when I see it” -- and, if pressed further, I’d say that essays, like all of the pieces in Multiply/Divide, are about ideas whereas stories are about, well, stories. In “Cleveland,” which Walters labels as fiction, the narrator invents a documentary project for the chance to interview the experimental playwright Adrienne Kennedy. Who knows if Walters ever did such a thing (she thanks Kennedy “for serving as instigator and metaphor” in her acknowledgements), and who really cares? “Cleveland” is an essay about “a fundamental insecurity I couldn’t overcome,” Walter’s explanation for stalking Kennedy, and delves into the insecurities she’s experienced as an artist, lover, and parent. 3. The way stories are told and retold, deconstructed and reconstructed, is the major theme of Multiply/Divide. Walters is essaying the story (here I’m using the verb form of essay, “to put to a test,” partly to be clever, partly because it’s the most appropriate word choice, and partly because this word choice confirms my theory that every piece in Multiply/Divide is an essay) as she explores how people, like my patients, fit their narratives into their current frame of mind. The book’s first essay, “Lonely in America,” begins, “I have never been particularly interested in slavery,” and goes on to recount the author’s experience researching a gravesite for slaves recently discovered in Portsmouth, N.H. Her investigation into this gravesite follows, and by implication was inspired by, a trip to New Orleans to view the wreckage of her Aunt Lou’s home in the wake of Hurricane Katrina. The account of how her New Orleans relatives have been abandoned by the government juxtaposed with her own frustrated attempts to explore the gravesite in a fairly tony (and oblivious) section of New Hampshire depicts an author who is interested in all forms of slavery, past and present. It’s not just people who are reshaping their narratives in Multiply/Divide. Cities, towns, and neighborhoods also recount their histories and often do so with a similar blurring of fact and fiction. Walters dissects people by focusing her gaze on their places as much as their personas, and her various approaches to these dissections reflect ambivalent feelings about such places. In “Manhattanville, Part One,” she uses an intimate tone in describing the subtle and sometimes not-so-subtle racism she encounters raising a mixed-race child in a section of New York City that sits between the affluent Morningside Heights to the south and poorer Harlem neighborhoods to the north and east. When an older white man approaches her outside a hardware store with the warning that her son will “sell you off in an instant,” the scene and its dialogue (written in italics, not quotes) strike a deliberately hazy quality: Is the old man, a representative of Manhattanville, supposed to be a prophet, a relic, or just a lunatic? A later essay about this same neighborhood, “Manhattanville, Part Two,” takes a journalistic approach recounting the murder of a promising high school basketball player in a local housing project side-by-side with tales of the ongoing construction in and impending takeover of Manhattanville by Columbia University. Walters, an academic who teaches at another Manhattan-based university, has infiltrated this neighborhood, too; her struggle to align with the aggressed, rather than the aggressor, in her home surfaces in an anecdote, slipped into this reportage, of walking her child home from daycare past a murder scene. “Once you know a place well, it is impossible not to feel impacted by the history that shaped it,” Walters writes. “And though I know these stories and have, at times, lived in the midst of them, they are both mine and not mine, though facts can sound like my truth in the moment I speak them.” We are the cities we live in, and the cities we live in are us. People are places, places are people, facts are fictions, fictions are facts, and all of these players serve us in the stories we tell. 4. “What do you think is going on?” I asked the patient’s wife. The patient’s kidney disease was in complete remission by his labs, and he said he felt fine, but his wife insisted that he still wasn’t back to his usual self. In her opinion, he was too weak. “To me, it seems very different from when…” his wife said. “It's the same weakness I've had for years,” the patient interrupted, “and it's not as big a deal as you're making it out to be.” He glared at his wife. I tried to defuse the situation. “One of my professors in medical school used to have a saying,” I said, “that if you're at the track and the jockey wants to give you a tip, you take it.” I smiled. The patient relented and let his wife explain why she was worried that a stroke had been missed at some point. “Okay,” the patient said when she finished, “now can the horse speak for itself?” I listened to the jockey, not the horse, and sent him to a neurologist. “There’s no stroke,” the neurologist told me over the phone, “but there’s certainly weakness. I think he may have myasthenia.” By which he meant myasthenia gravis, an autoimmune neuromuscular disorder that, if untreated, can be fatal. Within a week, blood tests confirmed the neurologist’s hunch. Later, I reflected on the patient’s luck that his wife spoke up about her concerns, and my luck as his doctor that I believed her more than him. I wondered why he downplayed his weakness to me, and why I trusted his wife’s story more than his. Walters might argue that the setting of our conversation, a doctor’s office, held the answer. In that office, all three of us had a story we wanted to tell. The patient, whose kidney disease was in remission, wanted to think of himself as healthy, regardless of whether he was truly at full strength. His wife wanted help, and she felt safe to ask for it in an over air-conditioned exam room. And me, who knows what I would have said or done if I’d heard this story in another arena, if, for example, an aunt pulled me aside at a family gathering to express concern about an uncle’s strength? All I can say is that I sensed a lack of closure in my office. The patient was ready to end his story, even if it relied to some extent on the fiction that he was well, but his wife felt that her version was still evolving. She didn’t know what was going on. She couldn’t give me an answer to my question. She needed more -- more places, more people, more facts, more fictions -- and, at that moment, so did I.