Horseshoes

Those who suffer illness learn by hearing themselves tell their stories, absorbing others’ reactions, and experiencing their stories being shared.

- Arthur Frank, The Wounded Storyteller

We stand together at the clinic room door, preparing to enter. “Tongue cancer. This is an 78-year-old man with an oral cavity mass and some memory loss. He had an ulcer on the side of his tongue for a few weeks which was biopsied by an outside doctor. No imaging yet. The lesion is tender. His wife died several years ago. He’s in there with his daughters.”

I nod at the resident. He is solid and introspective. I look at Tanya, the medical student, who is standing in our little circle of white coats. “Any other details I should know about him?” I ask.

“Not really,” she responds. “He’s very quiet and lets his daughters answer for him. He is aware of his memory problems and knows that he needs surgery. He’s pretty healthy.”

“Okay,” I say. I knock and open the door. My new patient sits in the exam chair. His two daughters smile when I walk in; one has a notepad in her lap. We all shake hands.

“I’m Doctor Campbell. You’ve already met Dr. Richardson and our student, Tanya, right?”

“Yes,” they acknowledge.

The resident and the student are attentive. The resident sits at the computer, ready to work on the Epic note that will tell the billing system what we have accomplished. Tanya stands near the daughters. Everyone leans in.

As I often do, I open with, “Let’s jump to the end. So, from what Dr. Richardson has told me, you have a very early cancer. Stage I – the earliest we see. You will need surgery, but you have an excellent chance of being completely cured of this with surgery alone. Depending on what the pathologist tells us, you probably will not need radiation or chemotherapy.”

The patient smiles weakly and looks at his girls, possibly seeking reassurance. "That's good news, Dad!" His daughters are clearly happy to hear this.

This is where I usually review the medical history and then wash my hands to begin the examination. However, I want to know a bit more about what he has heard and processed. In addition, I have two trainees in the room who might benefit from seeing how personal stories can interweave with illness.

I sit before him. “Where did you grow up? What did you do before retirement?” I ask him.

He tells me that he grew up a few blocks from where he lives now. He never moved away. “I worked in a factory in my home town. Before I retired, I worked in sales for a while." I note that he tells the story without enthusiasm. His daughters confirm his story. Well, I think, his long-term memory is intact. 

"Here's another question," I say. “What kinds of things did you do for fun?” 

At this, he lights up. “I loved horseshoes!” he says as the girls nod. "You know horseshoes? I had 18 ringers in a row one time! Can you imagine that? 13 another! You have to know how to throw the shoe!” He partially stands, bracing himself on the chair and letting his right arm swing free. With a gnarled hand, he demonstrates his technique in slow motion. “You grip the top of the shoe like this…” he pretends to be holding a horseshoe… “and bring your arm up like this. Here's the twist so that the shoe leaves your hand flat. It makes one rotation in the air before it reaches the stake. Then, plonk! It drops down and you score! Then you do it over-and-over.”

“Are you still competing?” I ask.

“Nah," he responds. "Not for a few years.” The room goes silent.

“Dad, tell him about being in the state tournament.”

"Oh, yeah!" He lights up again as he describes some of his adventures. The worrisomely quiet man has become irrepressible. The key to him was horseshoes.

We go on to schedule his surgery. A discussion that might have been anxiety-provoking is easy and collaborative. The daughters ask excellent questions and the patient listens. He asks how soon we can operate. Soon, we are shaking hands again and they are on their way.

“What did you learn?” I ask Tanya. 

“That was really interesting,” she says. “Now I know more about managing tongue cancer.”

“But,” I ask, “do you know more about horseshoes?”

She laughs. “I sure do,” she says. “That was amazing. He really seemed to enjoy talking about his story.”

And so he did. By drawing out his narrative and putting his cancer in the larger context of his life, his passion had driven the conversation. It took only a couple of questions for him to go from hesitant to animated; from being a man with a memory problem to being a former state-level athlete; from being identified as a tongue cancer to being a person with tongue cancer.

The approach satisfied me, lifting me for the rest of the day. I felt renewed.