My eyes opened with the familiar heaviness of a Monday morning, and as I began to pull myself out of bed, I felt a shooting pain in my neck. I was alarmed, but not wanting to be too dramatic, I repositioned on my side, pushed off and got to my feet, struggled to put a dress on without moving my neck, and headed to class. Finding that the painless range of motion in my neck was so limited that I could not look down at my notes, I decided I needed to do something about it today.
As a medical student, I know the rules of triage. The question wasn’t if I would see someone, but who. My primary care doctor couldn’t see me for a week. An orthopedist might turn my neck pain into a surgical problem. The ER? I could already picture myself sitting for six hours under fluorescent lights only accruing additional reasons to have neck pain. I scrolled through MyChart until I found a physiatrist who looked reasonable enough and, most importantly, had an opening that afternoon.
By the time I made it to the appointment, the pain was steady, but the anxiety was worse: I was in my neurology course in medical school, and I couldn’t help thinking about scary things like meningitis or even ALS. The exam room was cold and quiet. The nurse handed me a clipboard and asked the familiar question: “What is your pain on a scale from one to ten?”
The hidden meaning of the pain scale
I hate that question. I have heard it asked many times in clinical encounters, but at that moment, it felt impossible. As I stared at the cartoon faces grimacing, I realized that the number mattered less than what it revealed about me. Some patients grimace and whisper “three” while others chat comfortably and say “nine.” The scale tells you about their pain, but also about their history with tolerating suffering, with trust, with being believed.
Sitting there, I thought about a patient, Mr. P, whom I had met recently in the hospital. He had come in with altered mental status, found to have diabetic ketoacidosis. It was his third admission in 10 years. His A1c was 18.5 (a value above 6.5 is enough for diabetes). He had lost a toe to osteomyelitis, couldn’t get insulin for months because he hadn’t seen his doctor, and had recently stopped methadone after relapsing on heroin.
When I first met him, he was guarded and mechanical. He told me about a “toe scratch,” a missed appointment, a “mix-up” with his pharmacy. He spoke in fragments of the medical system’s language, as if trying to convince us and himself that this was all just a logistical error. But with the help of a skilled psychiatry preceptor, he began to open up in that very conversation. He told us about the relapse, about how heroin had crept back in, about the shame that kept him from asking for help.
I thought about him as I sat in that cold room. How quickly I had moved to seek care, how natural it felt to demand relief, and how my risk-averse mind had jumped to worries about ALS or meningitis. I hadn’t waited for my pain to prove itself. He had waited until his body forced him. I trusted that someone would help me. He had learned that the system might not.
Timing as a diagnostic clue
It struck me that understanding when a patient seeks care isn’t just useful for humanizing them; it is diagnostic. A patient like me who rushes into the clinic for a bad neckache is unlikely to have been tolerating serious symptoms quietly for months and is often more forthright in reporting her symptoms. A patient who presents only once a mass is large enough to obstruct breathing, or an infection deep enough to threaten amputation, has probably been far sicker for far longer than their words alone might suggest.
Mr. P’s story, set against my own, reminded me that delay itself carries meaning: It signals that we need to look deeper to search for what the body has endured silently and what the patient might not be ready to say. To care for patients like Mr. P requires learning to read a relationship with the health care system as a diagnostic clue, and to listen for what is missing as much as what is spoken.
We are taught that diagnosis begins with pattern recognition: the careful noticing of what fits and what doesn’t. But some patterns aren’t found in lab values or imaging. They show up in timing: in what finally brings patients in, and in how much they have learned to endure before they do.
I would later learn that my neck pain was due to a cervical disc herniation pressing on my spinal cord, resulting from my being a bit too eager in the gym. The diagnosis closed a loop in my own story, but it opened a larger one in how I think about patients. I am learning to pay closer attention not just to disease, but to how long someone has been living with it by the time they decide to ask for help.
Gillian Zipursky is a medical student.
