The Power of Privacy

The Power of Privacy

Vijay Gopichandran

“Sir,23-year-old man who has come with weakness, tiredness, palpitations for 2 months. I heard some strange sounds on auscultation of the heart. Could you please take a look”, was what my colleague told me when she left a thin built, handsome young man in my room who was accompanied by a tall, overprotective mother. I thought it must be a murmur of some sort. So, I decided I will re-do a history before I examine this young guy. I asked him, “tell me, what is the problem? What brought you to the clinic today?” He did not answer me, gave no response and looked at the side towards his mother. She answered, “Doctor, he is always very weak and tired. He is unable to go to work. He is always complaining of breathing problem and fast heartbeats. He is weak.” She had a very complaining tone. Every time she kept saying “he is very weak doctor” with a frown on her face, I was cringing in my seat. Why is this woman so condescending? She was probably very much worried about her son. But her facial expression, body language and tone of voice were not the least comforting for her son. He was sitting there with his face looking down, his whole body slumped, and he was shaking his legs nervously as he sat uncomfortably in front of me. In an attempt to get him to talk to me, I asked him again, this time looking directly in his eyes, “tell me, I want to hear from you. What is happening to you? What is the problem?” He avoided eye contact, looked right back down at his feet and answered, “I feel tired”. He did not say anything more. In order to get him to speak more, I encouraged, “mmmm, I want to understand more. Tell me. what makes you tired?”. He very shyly and in a low voice replied, “work makes me tired” and looked away from me. I wanted him to talk to me. So, I again asked, “I cannot help you unless you tell me what is wrong. What happened?”. To this the mother jumped in to answer, “Doctor, I told you no? His brain is not ok. About 3 years ago he had a brain fever. After the brain fever his brain became…..” and she gestured by rolling her index finger against her own temple. I was trying to take a history, but I was being stymied repeatedly by his reluctance to talk to me and his overpowering mother who was taking over the conversation. At the pretext of examining this young man, I asked his mother to leave the room. When she left, I asked him, “what work do you do? Where do you work?”. He replied in a soft voice, “I am housekeeping. In Sholinganallur”. I felt a bit encouraged as he was answering me now. But before the answer he very consciously looked at two other students of mine who were sitting near me shadowing me in the clinic. I was planning to ask them to leave the room to give us some privacy and at that precise moment one of my students who is now an intern herself voiced the opinion, “Sir, shall we leave the room?”. I was so grateful that they wanted to leave the room. They left and now we had the room all to ourselves. I now asked him, “Tell me now, what is the problem”.

He now was a different man. He looked at me in the eye. In his eyes, I could see the eagerness to communicate. I could literally see him telling me with his eyes, “help me”. He started getting vigorous involuntary twitching of the muscles of his face as he made a great effort to form words and tell me, “I am feeling tired. No sleep for many days. No food. Not hungry.”  I was touched and moved to hear so many words at the same time. I nodded my head in encouragement. He went quiet again. It seemed as though all those words were a huge effort for him. I asked him how his work was. This time when he tried to answer, his effort was much greater. He had a stammer and his face twitched more vigorously. He said very slowly and in a stretched voice, “tired at work. I sit here and there. Boss shouts. I feel bad. Sleep problem from starting work.” I gathered that he had recently started work. He was feeling tired and run down. Since he was feeling tired most of the time, he was slow at work. He was receiving slack from his boss for this. This was making him nervous, depressed and he was pulling himself into a shell.

I helped him lie down on the examination couch and started examining him. There were no focal signs of any nerve problems. My colleague has asked me to examine his heart originally. When I put my hand on his chest, I could feel his heart thump wildly against my palm. When I put my stethoscope on his chest, I could hear a loud S1 (happens when one of the heart valves closes) and a separate sound also referred to as the opening snap. There could be many reasons for these findings. I am not going into a detailed discussion of these. But it was starting to get clear that his gentleman had some issues which needed a detailed evaluation. Most importantly he was suffering from a form of post encephalitic sequelae of the ‘brain fever’ that he had a few years ago. This was making him slow in his cognition and processing of higher functions. More than anything he was suffering from low self esteem because of the neurological problem and social disability because of it. He was also feeling low and depressed because of this. Most of his problems could be explained by these complications. He needs evaluation of his heart function. Meanwhile, I started him on anti-depressant medications with a hope to help him feel better, get a better sleep and appetite.

On our way back home from the clinic today we were discussing the Mahabharata and what it teaches us about the right and wrong things in life. There is Bhishma of the Mahabharata, the bachelor prince, who sacrifices his life to satisfy the lust of his father, as the father of the woman whom his father desires, seeks a vow from Bhishma never to marry or covet the throne in order for him to secure the future claim of his daughter’s children to the throne. Bhishma on one hand is this righteous, self-sacrificing and honourable patriarch and on the other he does heinous and ghastly acts of treachery, cunningness and stealth to bring innocent women as unwilling wives for his brother. From the common perspective, Bhishma is a unfair and cunning man. But from his own perspective he is an honourable man protecting his father’s kingdom and bringing it glory and fame. I could see the moral conflict, very similar to this in case of the patient whom I had seen today. He had an overpowering mother who was unforgiving of the fact that he was weak and unable to provide for the family. From my perspective she was not a very good mother. But from her own perspective, she was wishing the best for her son. She wanted to protect him from the mock, jeer and evil intentions of the people around him. She just did not know how best to channelize her concerns and worries.

I also realized the immense power and strength that privacy gave people in a clinical encounter. In my clinic I often wonder whether privacy is relevant at all. The clinic is a small room with an even smaller waiting hall. At the peak time, there are often about 20-30 patients waiting in the small waiting room. Many times, they just overflow into the consultation room. Each one wants to get inside the consultation room before the other and so they all crowd up around the door of the consultation room. Often, I am sitting there inside talking to the patient and the other patients are just standing right there watching, listening and sometimes intensely concentrating on our conversation with even a nod in their heads. There is no semblance of privacy. In a clinic severely constrained by space and time, it becomes a huge challenge to offer privacy to the patients. But today, when seeing this young man, I clearly understood the magic that privacy can do. The young man who was so reluctant to talk when his mother and my students were in the room, opened up more freely when I offered him privacy. I don’t know how much valuable clinical information I am missing because of the ‘open for all’ that is often in offer to my patients. Many times a open hearted private conversation with a doctor can solve more issues than many tests, scans and medicines. I wish I can routinely offer more privacy to my patients.