I was a newly minted intern beginning an internal medicine residency in a city hospital, located in a gritty, working-class neighborhood. Sitting in an examination room, I awaited the arrival of my first clinic patient with a mixture of apprehension and eager anticipation. She was to be my patient and I was her doctor, a heady feeling after long years of medical school. I would try to look serious, and sound older and wiser than my 25 years. But would I know what to do? Of course not.
Mrs. M strode in, plopped into the chair, and shoved a large cardboard Box at me across the desk. Tentatively, I peered into the Box. Inside was a tangle of straps, buckles, elastic, and ribs. My expression must have been one of deep bewilderment. “It's a corset!” she snapped impatiently, “So how do I put it on?” I had no idea; I had never seen anything like it before. Rummaging through the Box, I could not find any instructions. At that point, I could reproduce the Krebs cycle from memory and rattle off the causes of metabolic acidosis, but nothing helpful came to mind; there was nothing in my medical training that prepared me for this moment.
She was a dour-looking woman of 70 years, with unruly shocks of gray hair and bulldog jowls. Her voice was gravelly, lowered several octaves by years of smoking. She had a protuberant abdomen that accentuated her portly frame, for which her previous physician ordered this custom-made corset. Now he was gone, and I was responsible. So, Mrs. M and I spent the entirety of our initial session strapping her into this contraption using the trial and error method. I strained to ratchet the fasteners tight: “Inhale, Mrs. M!” We were a parody of that famous scene from Gone With the Wind in which Scarlett O'Hara was forcefully winched into her bodice. Finally, Mrs. M seemed satisfied with the fit and harrumphed her way out. My outpatient clinic was off to a weird start.
About 1 month afterward, Mrs. M presented for another appointment. I did not recognize her at first as she sat in the waiting room. Her figure was trimmer, reinforced by the corset. But also, her hair was neatly coiffed, her face was powdered nearly white, and she wore bright red lipstick. And she was smiling! She had been transformed into a pleasant, agreeable, and cooperative patient. I was astounded by how much her self-image and attitude had improved.
Left to my own devices, I might have led by counseling Mrs. M to modify her diet, exercise, lose some weight, and stop smoking. That advice more than likely would have fallen flat. It would never have occurred to me to prescribe a corset. But thanks to the wisdom of my predecessor, the corset achieved immediate results and paved the way for later, more conventional recommendations. Somehow, he discerned that addressing her self-image would be the most effective approach to setting her on the path toward better health. That was a revelation. In inheriting his patient, I benefited from this insight.
In a career that has spanned over 30 years, I have seen my share of patients with rare disorders and dramatic courses. But I like to think back to Mrs. M and her corset not only to laugh at my youthful inexperience but also because this was one of the formative episodes that shaped my outlook on primary care. She showed me early on the importance of getting to know my patients well, and of thinking beyond the obvious. One of the most rewarding aspects of practice has been cultivating long-term patient-doctor relationships—becoming familiar with their life histories, beliefs, passions, and tendencies. At times, I have relied upon that personal knowledge to nudge my patients in the right direction, figuratively prescribing a few “corsets” myself. The seemingly minor interventions we make every day, undertaken with a keen understanding of our patients and sometimes with a bit of imagination, can alter the trajectory of their well-being and greatly enhance their quality of life. And for me, it all started with a large cardboard box.