Differential Diagnosis by me 5/31/2008

An English speaker in her forties and admitted to the dual diagnosis rehab three weeks ago, she agreed to talk to us, three medical students visiting the ward for the day. A 160cm, about 80 kg, dark skinned, dressed in a black shirt and a black pair of capri and a flipflop walked in heavily. Her hair not well kempt, she seemed to sink into the chair, without holding her own stature. Her name cannot be revealed and yet her story was shared with many, including myself. But, by the nature of the medical profession and of being uni-lateral healers, the stories of the medical personnel fade into the background, including my own.

Today is the story of Oshrat.

As medical students, we were expected to do a so called medical interview, to come up with a differential diagnosis and treatment plan. We took turns, talking, perhaps for the first time, to an alcoholic of five years. By so doing, giving the well famous exam questions about alcohol addiction a face, at last.

She was dating a man younger than her for ten years, and who was a drug addict. It was during dating him that she began to drink excessivly. The drinking increased when she was robbed in the post office where she used to work. She, then, continued to have nightmares at night about the robbers. Later, she was fired from her job. With that, her drinking increased from that in the evening, to that in the morning, finishing one bottle of vodka a day. She did not take drugs. She had tried to commit suicide twice. She became appologetic with her frowning face, admitting that she did not know what else to do, that she found herself alone. She could not stop drinking and told her mother to admit her to the detox program, to take her away from her abusive boyfriend.

She had been married previously, with two sons. An older one who was travelling in the States and who told her he never wanted to talk to her, because she lied every time she said she was going to quit drinking. Her younger son, who was still in the army, still talked to her. Occasionally, she talked to her ex-husband. She spoke good English because she had left to California with her ex-husband and children twenty years ago, where she was not able to work initially, and then as her children began to go to school, she joined a culnary school. Here, at the mention of the study of the culinary arts, her faced lightened up for the first time, and she smiled.

When she was going to leave, she was going to move to a place far away from home so that her boyfriend was not going to find her. Her dream was to join a cosematics course, where she could learn to do manicure and pedicure. Here, also, her face lightened up for the second time, and she smiled. She explained about what her day looked like in the detox program- getting up in the morning, having a meal with everyone else, sitting around and talking for a bit with others in a group, doing some arts, and with that were the other two meals. She said that she felt different in the program, that she was not alone.

We thanked Oshrat as she left. The doctor teaching us said, "Well, it is nice what you asked, but you did not ask psychiatric questions. You have not formulated a differential diagnosis." During my first year of medical school, upon every patient encounter, I wrote about their story, just like I had writen the story of Oshrat. During my second year of medical school, I wrote about working with cadavires. During my third year of medical school, I initially wrote about the story of every first patient encounter in each ward. By the end of each rotation, talking to patients became about formulating a differential diagnosis and a treatment plan, and I myself lose my sense of the whole story of a person. There will be many Oshrats that I wil interview, formulate a differenetial diganosis and a treament plan, and with that, I will not be able to write about their story the same way I have writen about Oshrat here.

"I formed my own differential diganosis," I thought to myself, in reply to the doctor teaching us. "Differentual Diagnosis one: we all struggle (some with drugs). Differential Diagnosis two: we all struggle(some with alcohol). Differential Diagnosis three: we all struggle (some with relationships). Differential Diagnosis four: we all struggle (some with self-esteem). Differential Diagnosis five: we all struggle (some with the meaning of life). Differential Diagnosis five: we all struggle (some with our past). Differential Diagnosis six: we all struggle (some with a physical disease). Treatment plan: grace."

Grace (u2)She takes the blame
She covers the shame
Removes the stain
It could be her name
GraceIt's a name for a girl
It's also a thought that changed the world
And when she walks on the street
You can hear the strings
Grace finds goodness in everything
Grace, she's got the walk
Not on a ramp or on chalk
She's got the time to talk
She travels outside of karma
She travels outside of karma
When she goes to work
You can hear her strings
Grace finds beauty in everything
Grace, she carries a world on her hips
No champagne flute for her lips
No twirls or skips between her fingertips
She carries a pearl in perfect condition

What once was hurtWhat once was frictionWhat left a markNo longer stingsBecause grace makes beautyOut of ugly thingsGrace makes beauty out of ugly things