“I am so tired,” Melanie, thirty-two, says at the beginning of each visit, twice a week, for the past year. “I think you should go to your primary care physician to check that out,” I say, repeatedly. “I don’t want to go to the doctor. He is going to tell me I am crazy.” Melanie says, inviting me to argue with her. “Well, what if you tell him that I thought you should go?” I respond. “Oh, I don’t want him to know I am seeing a psychiatrist. Then, he will really think I am crazy.” Melanie says, reminding me that I am part of her secret life. She does not wish to disclose our relationship to anyone. “Why do you think you are so tired?” I ask, probing to see whether she thinks her fatigue is secondary to her mental state. “I think I have a blood disorder of some kind, but I am too reluctant to check that out.” Melanie says, knowing that I will be frustrated by her comment. “If you do have a blood disorder then you could feel much better if it were treated,” I say, stating the obvious, but feeling like it needed to be said. “I know that,” she responds impatiently. “How can I help you?” I ask, pointing out that she has put me in a bind. “I know you are not a primary care doctor, but I wish you could order the lab tests,” she says, almost begging me, but knowing that I won’t do that. “Well, even if I did order the tests, I would need a primary care doctor to review the results with me,” I say, again, stating the obvious. “I know. Forget I asked. I will just be tired all the time,” Melanie says, firming up her original position. “That’s a shame,” I say, pointing out that she is not taking care of herself. “I know,” Melanie responds with tears in her eyes. “I wish I knew how to take care of myself,” she says with deep feeling. “Well, maybe I can help you with that,” I say, reminding her that is one of the reasons she comes to see me. “You are just one of the few people I trust,” she says, reminding me that one of her reasons she is reluctant to pursue a work-up of her fatigues is a basic mistrust of most people. “So, maybe you can use your trust in me to mobilize you to see a primary care doctor, since I think it is important that you go,” I say, trying to use our relationship to mobilize her to constructive action. “Maybe,” Melanie responds, sounding a bit more open to the idea.
Shirah Vollmer MD 