Help.net

by Stefano Costantini

What a day.

The Doctor gets into his office and shuts the door behind him.

He's tired. Disgusted, almost.

He takes off his white coat. He hangs it to the back of his desk chair. As usual.

He does this to separate his day job and from his personal life.

White coat off: he's free.

White coat on: he's at work.

At work in a place he despises. He used to like it. Great colleagues. Interesting cases. And he was getting along with the Head of Neurology, his department.

Not any longer. He's not in the good books anymore. Now his colleagues seem aloof. Distant. The Doctor doesn't recall the moment when things started to change.

He doesn't think he's done anything wrong. It must be his personality, coming to the surface, step by step. So, gradually, they've started disliking him.

The Doctor doesn't care about them. They can go to hell. He still has a job. And he still gets his money, every month.

Yes, his money. Shame it's not quite enough.

The Doctor likes to spend it. He never says no to himself. So he was looking for a source of extra income.

But he's found it, luckily: this website for which he's been working for a while.

Hypochondriacs write, asking for advice. And a pool of expert physicians addresses their concerns.

No real diagnoses, of course. They couldn't do that. Not without actually seeing the patients. Most of the times they just advise the patients to speak with their own real doctor. To undergo some diagnostic tests.

The Doctor doesn't know whether this helps any of the people who write to the site. After all, if they are worried, they will always be.

The important thing is that this helps the Doctor. For every post he writes, he gets a fee. Not much in itself, but it quickly piles up. And most patients write a few times.

He wakes his computer up. Time to park his day job for a while now.

He logs in. There are already a few messages from people seeking his expertise.

The Doctor scans them quickly. Based on just reading the subject lines, they all seem to be pretty much run-of-the-mill.

He reckons he could deal with all of them in a few minutes. Easy money, indeed.

But he's bored. He needs a bit more than that. Something a bit outrageous, almost ridiculous, to keep him entertained.

There it is: a patient is complaining of a persistent, yet light, headache. He's had it for a couple of days.

And the Patient is worried. He thinks he might have a brain tumour.

Typical. The Doctor has seen many of them.

This case is not as exciting as he was expecting, after all.

Plenty of people that read all sorts of things on the internet. And they worry.

So, now the Doctor is going to examine a potential brain tumour over the net.

Not really though: without seeing the Patient, he can't. He just tells the Patient not to worry too much. It may be nothing, really. If he is concerned, the Patient should speak with his doctor and perhaps arrange a neurological consultation.

The Doctor apologises that he can't provide a firmer opinion, but, the are limits to what the net can do. It's still better than nothing, at least for the Doctor.

The Patient shouldn't worry, though, the Doctor writes. In a few days the pain will probably go away.

And should he still be concerned, he tells the Patient, he could write back in a couple of days.

The Doctor clicks on 'Send'.

Done.

Ka-ching.

Next.

***

A few days pass.

The Patient has written again.

The Doctor knows that this is not uncommon.

In fact, it's from people like these that he makes most of his money.

The Doctor cares, because now this is his primary job. Not in terms of money. Most of his income comes from his job at the hospital. But in terms of respect. Here people look up to the Doctor. They listen to him. They rely on him for their happiness.

The Patient does too.

He's worried. His headache hasn't gone away.

There are also some alarming news: these are the words he actually uses.

The Patient is not sure, but he thinks that he lost sensation on the right side of his upper lip, at least for a moment. It didn't last long. But it was a weird feeling. Perhaps the tumour is pressing on a cranial nerve, the Patient wonders.

The Doctor can see that the Patient is worried. A lot. He says he has been spending his time touching his lips, with various objects. Pens. Keys. His glasses. He checks whether he still has sensation. Not just there. In other parts of his face, too.

The Patient asks the Doctor whether he agrees with his hypothesis. Either that, or could it have been a Transient Ischaemic Attack? A mini-stroke, in other words.

The Doctor thinks that this is a proper hypochondriac. If he manages him well, he's going to make quite a bit of money from him.

Nothing unethical, of course. He's just doing his job.

And he's not going to give him a firm diagnosis. If he did, they would strike him off the site. Liability management.

The Doctor writes back to the patient. He's sorry that his headache has not gone away. He's also sorry to hear the recent developments. Again, he urges to patient to get a neurological consultation. The lip sensation issue may be due to a variety of factors. Cold weather for instance. It's winter. A bitter one. Staying outside for a long time may lead to something like this.

The Doctor adds that the Patient shouldn't worry too much while he waits for his consultation. And he should stop touching his face all the time. The more he touches it, the more he will think he's got some changes in sensation.

The Doctor knows that it will be a useless neurological consultation.

He is tempted to tell the Patient that he hasn't got anything. But that wouldn't work. He recognises the pattern. You don't cure a hypochondriac by telling him he shouldn't be one.

For a few seconds, the Doctor feels bad. Maybe the Patient doesn't have anybody to speak to? He's tempted to ask.

He doesn't do it, of course. That wouldn't be professional.

He clicks 'Send'.

He earns his fees.

Perhaps his response will calm the Patient down.

Perhaps.

But the Doctor knows that the Patient will write again.

***

It's been a week. The Patient hasn't written back.

Perhaps the Doctor was wrong?

Maybe the Doctor has managed to calm him down.

Maybe the Patient has found someone closer to him to speak to.

That's not good, the Doctor thinks. This doesn't earn him any money. Nor any respect.

So far, the other cases he's dealt with online have been straightforward. All stuff for which the answer can be found on the net.

The Doctor is bored.

And tired.

And stressed.

Yes, it must be the stress that makes him sleep badly. That makes him forget things. Sometimes he's so absorbed in his thoughts that he doesn't remember how he does things.

For example, today he doesn't remember how he got to the office in the morning. He just found himself at his desk. But, after all, it's the same commute, day in, day out. It's easy to get distracted.

Still, the moment he noticed this, he got a little scared.

It's not the first time this happens.

He should take a break. A holiday perhaps.

Maybe the Patient has gone on holiday.

Good on him.

***

Could lower arm weakness be a symptom? The Patient has written again.

The Doctor has almost missed him.

There have been developments, apparently. The Patient didn't take any time off. Instead, he's spent the weak worrying about new symptoms. He's sure that he has a brain tumour, but he wants the Doctor to validate his conclusions. He's read that a brain tumour, by pressing on some nerve centres at the base of the spine, could lead to asymmetric strength loss in the lower arm and hand. Basically, one arm gets weaker than the other.

That's what the Patient now has. He's done several exercises, lifting weights with both arms to see whether there is any difference. He says there is, but he is not 100 percent sure. What does the Doctor think? The Patient has asked some of his friends, but he says that they've all got tired of listening to him. He doesn't blame them. He knows he's become quite a bore. But he just can't help it.

The Doctor doesn't know what to say. Of course, anything is possible. He has seen this in the literature, in some paper or another. He can't remember. His memory is not what it used to be. But this symptom, even together with all the other ones, doesn't prove anything.

The Doctor writes back.

It's the same story all over again. Without diagnostic tests, he can't give the Patient any firm conclusion. He repeats that the Patient shouldn't worry. But, has he booked a neurological consultation? It would be good to get one, as the Doctor said before. Mainly for the Patient to calm down.

The Doctor sends his message. Now he's beginning to worry about the Patient. He's sure that he doesn't need a neurological consultation.

But he definitely needs a psychiatric one.

He hasn't said that. Yet. He will, if the Patient keeps on writing. It's clear that the he needs help.

After a while, the Doctor finds himself at home, eating a lonely dinner.

He doesn't remember how he got there.

It's stress, he says to himself.

Just stress.

***

The Patient wrote his message in the middle of the night. He woke up all of a sudden. Sweating. With palpitation. He doesn't know how to put it, but he felt like he was fainting in his sleep. No, it wasn't a dream. It was real, otherwise why would he have felt like that? Now that he thinks about it, it's not the first time this has happened to him. Could this be another symptom of the tumour, he asks the Doctor.

The Doctor doesn't know why the Patient hasn't gone to the neurologist yet. He's told the Doctor that sometimes he forgets things. Who doesn't, thinks the Doctor, wondering about himself.

He feels that the consultation would be the only thing that could make the Patient feel any better.

That, and some Diazepam.

***

It's early morning in the Doctor's office. The start of another day. It will be a day like many others.

The Doctor doesn't feel like starting his usual round. Some time ago, he had his colleague's respect. Many wanted to be like him. He could feel that. Then, somehow, all this changed.

He still has students. And an assistant. But only because the hospital requires that. Every day, their faces tell him that they would like to be somewhere else. But what has he done? Has he been rude to any of them? He doesn't recall anything like that.

The Doctor shrugs.

Back to his real job, then: help.net.

Where he feels he is still worth something. Besides, the Patient needs him, he can't leave him alone. Alone in his bed. In the darkness of his room. Sweating. Then shivering. Feeling his heart in his temples.

The Doctor writes back.

Calm. Serene. Authoritative.

The neurological consultation should have priority, he says. There is nothing to worry about, but seeing the neurologist would make the Patient feel more relaxed. And, the Doctor is sure, all the other symptoms will also go away.

The Doctor thinks that he needs to be careful. He can't openly tell the Patient that his symptoms are probably psychosomatic. That the Patient is a hypochondriac. After all, that's a condition too. A psychiatric one.

The Doctor holds this back, for now. It isn't time yet.

That would be the next step: if the Patient doesn't get better, he'll tell him he needs to get psychiatric help.

The Doctor sits back. Careful not to crease the collar of his white coat, which is waiting for him on the back of his leather chair. It's usual place.

The Doctor puts it there in the evening.

The Doctor picks it up in the morning.

The Phases of His Day.

Now he has to start the one he likes the least. Shame it takes up most of his waking time.

He picks up his black fountain pen from the desk and puts it in his right pocket.

Its usual place.

***

The Patient has had his consultation.

At last.

It's been a week with no new news from the Patient.

Until now.

The Doctor has tried not to think about the Patient too much. After all, he's never met him in person.

The Patient should not have any role in the Doctor's life.

Never get attached to one of your online patients: that's what they told him when he signed up to provide medical advice. After all, he would never meet them.

He knows it. He agreed to that. At the time, it just made plain sense.

Yet, the Doctor can't help himself. He's spent the best part of the week thinking about the Patient.

At least when his day job allowed him. It's been one of those weeks. Add to that that his colleagues still treat him kind of weird, no wonder his stress levels are going up.

But he hasn't got time to worry about that now. He'll take better care of himself when things get quieter.

It's good news from the Patient at last.

He's had his neurological consultation. They even gave him an MRI scan.

All clear, it seems.

This makes the Patient feels much more relaxed. He's made him happy.

The Doctor doesn't know the Patient.

But he's happy too.

***

Here we go again.

As expected, the Patient has been happy just for a few days.

Something terrible and unexpected is happening, he writes.

Yes, of course, the test results were good, he acknowledges.

But the Patient does not trust them. They're trying to keep something from him, he's convinced of that.

He thinks it's either of two things. Maybe the tumour couldn't be detected. Too small, but already deadly. Or the Patient is beyond help, and there wouldn't be any point in putting him through any hopeless cure. Better a few good months than a year of suffering.

Either way, the test hasn't solved anything.

The Patient feels that his time is running out.

Can the Doctor help him?

All the symptoms are still there. Headache, lower arm weakness, feeling faint. He sees lights sometimes.

He's been running a few homemade tests of his own.

First, he tried to follow a light with his eyes. Can he do that? Does one eye trail behind? He acknowledges that, when you do the test on yourself, it may be difficult to tell. He asked his friends to film him. They refused: they think he's crazy. They told him that. To his face.

Then, he attempted to test his equilibrium. That's how: he closes his eyes and tries to stand on one leg as long as he can. He thinks he has some problems standing on his right leg. He fell a few times. He even hit his head on the chest of drawers. The fact that he has problems with his right leg doesn't surprise him. That goes well together with the weakness in his lower right arm.

Basically, it all fits, the Patient says.

He asks the Doctor what he should do. Friends and colleagues won't help the Patient. He understands why they might think he's crazy.

But the Patient needs help.

Can't the Doctor help him?

***

What can he do for a patient like this? He's hopeless. No word would calm him down.

The Doctor knows that this is not normal. The Patient is ruining his life. This won't end well.

The Patient needs help. Serious help.

He needs psychiatric help.

For that to happen, the Doctor needs to be frank.

He writes to the Patient. The Doctor doesn't think that the problem is neurological at this point. Instead, he reckons that the Patient would be better assisted by a psychiatrist. Now, the Patient could write to someone on the site, but the Doctor recommends meeting a psychiatrist in person.

It's the best strategy, the Doctor writes. There's nothing to be alarmed about, he tells the Patient. He just needs to do this to get back his quality of life.

Actually, the Doctor is not sure this would help though. Of course, he doesn't tell the Patient. But the Doctor has seen people like that before. It's a downward spiral.

Sometimes, he feels a bit like this himself. He certainly has his ups and downs.

He's still worried about the fact that he's distracted all the time.

He should really take a break. A holiday perhaps.

And, after that, he should get someone to take a good look at him.

If he can't help himself, how can he help others?

How can he help the Patient?

***

The Patient already knew that there was something wrong with him.

No, not the brain tumour.

He's already in psychiatric care, the Patient writes. He didn't say that before because he didn't think it was relevant. After all, it may well be the tumour that is preventing his brain from working properly. The cause of his psychosis.

The Patient doesn't think any of his doctors wants to help him.

Actually, none of his real-life doctors, to be precise.

But the Doctor does. The Patient can see that. And he understand that what the Doctor can say is limited. This is just a website. The Doctor has never seen the Patient. How could he give him a diagnosis?

But the Doctor's words have supported the Patient through these tough times. The Patient writes that he doesn't quite know how he would have made it without the Doctor.

The Patient hopes he hasn't been too much of a nuisance so far. And he also hopes that the Doctor would continue to help him.

The Doctor has become the Patient's lifeline, he says. He doesn't go out that much these days. He doesn't really speak to people.

Thank god the Doctor is there for him.

***

The Doctor has had enough of this.

He's not here to help.

Not anymore. He can't.

Of course, the Doctor could keep this conversation going. Every response his writes, the Doctor gets his fee. And, with someone like the Patient, things could go on, and on, and on.

But no, it can't be done. It wouldn't be fair. Even if the Patient thinks the Doctor is helping him, in reality he is just making the Patient worse.

The Doctor is sorry, but he needs to think about his other patients too.

And about himself, first. He's still stressed. Like he's never been before. His day job is a disaster. He's not sure he can carry on like this.

His personal life has crumbled too. Where are his friends now? His family?

Yes, he should take better care of himself.

So, the time has come for the Doctor to detach from the Patient. It will be hard, for the Patient, but the Doctor can't wait any longer.

He sits back. As always, he's placed his white coat on the back of his leather chair.

Today, the Doctor doesn't care if his coat's collar gets crumpled. He pushes the back of his head against the warm leather. He looks up at the ceiling and sighs.

He puts his hand into the coat's right pocket. He fishes out his black fountain pen.

He plays with it, while he thinks, running it through its fingers.

Suddenly the Doctor notices that he doesn't remember how long he's been sitting there. Another memory lapse.

He should really do something about that.

He unscrews the pen's cap.

A drop of black ink, lucid, perfect, falls on his right leg, leaving a round stain on his beige trousers.

The Doctor curses under his breath.

He'll have to deal with this too.

But first, he write his final message to the Patient.

Good-bye.

***

The Patient can't believe it.

The Doctor is dropping him.

The Patient wonders where he may have gone wrong. He knows he was insistent. All the real-life people around him have told him that he's crazy, that he should get help.

But the Doctor was his anchor.

Calm, serene, authoritative.

Now, what is the Patient supposed to do?

Just now that his symptoms are getting worse.

Headache, equilibrium problems, palpitations, lower arm weakness.

Loss of sensation.

Memory lapses too.

The Patient doesn't know how long these have been going on for. He just knows that sometimes he finds himself in a place, and he doesn't remember when he got there, and how.

This is affecting his job, as well as his personal life.

The Patient needs to take better care of himself.

He knows he's ill. Even if no-one wants to believe him, he'll carry on. On his own.

He's in his office.

He sits back on chair, carefully avoiding to crumple his coat's collar.

The Patient doesn't remember when he got there, exactly. He must have finished his shift on autopilot.

He scans the room. His fountain pen is lying on the table, cap unscrewed.

Initially, he doesn't understand why it's there.

Then, the Patient notices it.

A black, round, perfect ink stain on his beige trousers.

Barcelona, 23rd June 2013

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