I am not an intimidating person, but I found my last patient of the day huddled in the comer of the examining room, as if awaiting an executioner. She was in her midtwenties, and she clutched a sheaf of medical records against her chest like a shield. She had made the appointment to our clinic herself. The face sheet on her chart said “chronic abdominal pain.”
I introduced myself, sat down, and began to take her history. She had had severe abdominal pain since her mid-teens, but her description of the pain was so vague that no specific diagnosis sprang to mind. And her records disclosed that other physicians had fared no better. She had been seen at every major gastroenterology clinic in town, had gone through all the tests, and had tried all the medicines. What, I asked myself, kept her trudging from doctor to doctor on this medical odyssey? And what could I possibly do for her?
As I questioned her, I studied her with growing fascination. She was anxious and withdrawn, but nonetheless she projected a desperate courage, like a cornered animal making a defiant last stand. She kept her gaze directed downward, but every now and then I caught her staring at me intensely, as if searching for something. She wore a drab, bulky
sweater and oversized bluejeans, and her unkempt hair fell over her eyes. l struck me that she deliberately had done everything possible to obscure the fact that she was a very attractive young woman.
She seemed so uncomfortable talking about herself that I moved on to inquire about her family history. Her parents had emigrated from ltaly. Her mother had died when she was a young girl, and although she was not the oldest child, it had fallen to her to play the role of mother to her five siblings. She was a devout Catholic, who, like her mother, attended
mass every morning. “But I don’t take communion; she added. Her father was a baker, and through years of hard work now owned his own bakery, which she managed.
Now, cooking is my hobby, but baking is one culinary skill I have never mastered. So I was always on the lookout for good bakeries, for they are not easy to come by. I asked where her bakery was and if they made French pastries, one of my weaknesses. They did. “Are they as good as the French Gourmet Bakery’s?”, I asked, mentioning the name of a popular place near the medical center. “I’m addicted to their Napoleons.”
For the first time her eyes came alive. “I wouldn’t feed pastries from the French Gourmet Bakery to my cat,” she retorted. “The French learned all they know about baking from the ltalians; she informed me with an artisan’s pride. “It’s not as easy to make Napoleons as it looks – it’s very tricky,” she said, with a tone of voice that implied that she knew the secret but she was certainly not about to tell me. Her passionate outburst took me by surprise, but it faded away as quickly as it had appeared. The remainder of the interview was monosyllabic.
Her physical examination was entirely normal. I told her that I thought she most likely had a severe form of irritable bowel syndrome. She listened carefully, but said nothing. I prescribed a bland diet and the one antispasmodic she had yet to try, and asked her to return in 1 month. I was not optimistic.
I really didn’t expect to see her again, but she reappeared the next week. As before, she sat silently in the examining room, and responded to my questions with terse replies. Because she had become so animated talking about the bakery the week before, and because baking seemed to be the only point of contact I had established with this otherwise withdrawn young woman. I spent most of the visit asking her about Italian pastries: which ones sold on which holidays, what kind of yeast worked best, the recipes her father had brought from Italy. She was very knowledgeable. She didn’t mention anything about abdominal pain. I made another return appointment for a month later.
Again she returned the next week. This time she seemed a bit more at ease, but I noted the dark rings under her eyes. “Are you sleeping well?” I inquired.
“Because I have a nightmare.”
“A nightmare? The same nightmare every night?”
“Can you tell me about it?” She was silent for some time, and then took a deep breath, as if she had made a decision. Then, in a barely audible monotone, she described her dream: She is running, because she must get to confession before the priest leaves. But when she enters the church it is empty, dark, cold. She calls out, but there is no answer. Suddenly, unseen acolytes seize her and drag her to the altar. Her head is pulled back and holy water is forced down her throat to drown her screams. She struggles to raise her head and sees a procession of hooded priests holding long candles headed up the aisle toward her. I shuddered as I listened to her; the implication of the lurid imagery was inescapable.
“Were you ever sexually assaulted?” I asked gently.
‘When I was fourteen.” She was breathing now in short, rapid gasps. I didn’t know whether to continue or not. Her eyes said yes.
‘What happened?” With great effort she told me. She had been raped by her oldest sister’s boyfriend. He had come to the bakery late at night in search of her sister, but had found her instead. “There’s nothing dirty he didn’t do to me,” she sobbed, and now unstoppable, she poured out the grim details of her ordeal.
‘You never reported it?”
‘You never told anyone?” She looked up at me with an imploring face. “How could I tell anyone … it would kill my father and destroy my family,” she wept. ‘You’re the only person I’ve ever told.”
I felt completely out of my depth. I consoled her as best I could, and when her sobbing had subsided, I gently suggested a referral to a psychiatrist or a rape counselor. I’m a gastroenterologist, I told her, this is not my area of expertise. I had neither the knowledge nor the experience to help her, I explained. But she adamantly refused to consider a referral to anyone else. She didn’t trust them. I then understood that having unearthed her dark secret, I had become responsible for her care.
For weeks after her assault she could not eat. But then, insidiously, she fell into a ritual of penitence: She would sneak into the bakery late at night and stuff herself with pastries, then purge herself, and repeat the process until her stomach ached and she was exhausted. She was helpless to stop, for her bingeing ritual expiated her guilt and shame, albeit only briefly.
She seemed to derive great strength from the visits. When discussion became difficult, we talked about baking. I spent many evenings in the medical library reading as much as I could about rape and eating disorders. There was not much written, and after a while it seemed that I was learning more from my patient than from the clinical journals. Still uneasy with my unaccustomed role, I discussed her case with a colleague in the psychiatry department.
“Is she comfortable talking with you?” he asked.
“Does she seem to be getting better?”
“I think so.”
“Then you’re doing just as well as we could,” he declared.
The visits continued, and as the months passed I noted subtle but unmistakable changes: Her anxious look vanished and she began to smile; she gained some weight and remarked that she thought it made her look better; a touch of makeup appeared; she came to the clinic with a new hairstyle; she informed me that she had returned to school part-time and had received her high school diploma. She announced that she was taking communion again. Her visits came at longer and longer intervals.
I hadn’t seen her for 3 months, when she appeared just as I was about to leave the clinic. At first I didn’t recognize her, such was the extent of her transformation. She was vibrant, alive. And she looked beautiful—elegantly attired as if for a night on the town. I realized she had dressed up for me. I also sensed that something was completed, that this was a leave-taking. We sat down in the empty waiting room.
“I’m quitting the bakery,” she told me. “I’m going to travel to Italy this summer, and when I get back I’m going to start college full-time. I wanted to see you before I left so I could bring you these,” she said, handing me a white cardboard box, carefully tied with a bright ribbon. “Should I open it now?” I asked. She nodded.
Inside the box, neatly resting on individual doilies, were six perfect Napoleons, the pastry puffed high, the fondant a smooth glassy sheet, the chocolate chevrons meticulously aligned. “My father usually makes these, but he sometimes doesn’t get it just right. I made these myself just for you,” she said. I smiled and thanked her for her kindness. We talked a bit about her forthcoming trip. Then she stood to go.
“Thank you for believing in me,” she said.
“I should say the same,” I replied.
A thin film of tears shone in her eyes. She leaned toward me and kissed my cheek. “Goodbye,” she whispered, then whirled down the hall to the elevator. Just as the doors opened, she turned back and flashed me a radiant smile that warmed me like the sun. “Don’t eat them all at once,” she said with a mischievous twinkle in her eye. “It’s not healthy, you know.”
“A doctor doesn’t choose his patients,” the grey-haired professor who taught me physical diagnosis would say. “It is the patient who chooses the doctor.” I had been chosen to receive a gift of trust, and of all the gifts I had ever received, none seemed as precious. That afternoon, I left the clinic feeling exhilarated and full of love for my profession. That evening, after dinner, I opened my present and partook of the communion from the baker’s daughter.
1. Why do you think the doctor believed he wasn’t qualified or trained, and wanted to refer to a counselor or psychiatrist?
2. Why do you think that he maintained responsibility for her care? Would you have done the same? Why or why not?