Stuff is always there under the surface - stuff you don't hear about.  Patients come to see you and talk about their medical problems, stressors, and their pain; but they often leave out big issues.

My partner encountered that recently when working up someone with elevated liver tests.  He did a thorough exam and a good history and had no good reason for these tests to be abnormal.  After the lab work came back without a clear reason, my partner decided upon a CT scan.  He called the patient to tell about the results and the planned test, and instead got his wife on the phone.

"Has he ever told you about his drinking?" she asked.

"We talked about his habits, but he didn't tell me about anything excessive."

She paused and sighed, "Well, he drinks fairly heavily at times.  He thinks we don't know about it, but ever since the economy started going bad and his business started struggling...."

My partner listened as she went on to describe the obvious reason for the test abnormalities.  Wanting to get more direct information but not wanting to reveal the conversation with the wife, he called back when he could speak directly to the patient.  "Is there anything else that could explain the test abnormalities?  Do you drink much?" he asked him after explaining the further testing needed.

"No.  I just drink a little bit from time to time." the patient answered, keeping his voice level and confident.

People do this a lot.  There is a lot under the surface that nobody knows about.  Most of the time it isn't directly relevant, but other times it is.  Yet either out of embarrassment or because they simply don't think it is relevant, they hide their lives.

It makes sense that people do this.  We have people saying "how are you doing?" to us all day long.  These people don't really want to know how we are doing; they just are being polite.  They wouldn't really appreciate it if we did share how we were doing.  So when the doctor says "how are you doing?" the first impulse is to answer in the normal way.  We don't want to burden others with our big problems.  We don't want someone to make a big deal out of things.  We don't share who we really are because it feels very uncomfortable to do so.

Doctors need to remember this.  There is always stuff that is not being told.  I have uncovered this when people came in for inexplicable reasons or with perplexingly vague symptoms.  Nobody comes to the office without reason.  If it seems that way, it should be a clue that there are bigger things under the surface.

We also need to remember this with the people around us.  We think we know our friends and family, but there is a whole lot we don't know.  If you doubt this, think about how much you keep hidden in your own life.  Think about what would happen if you were really transparent about things.

Sometimes it's much easier to keep things quiet.

Don't forget that.

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