Up the Down Escalator: Medicine, Motherhood, and Multiple Sclerosis

By Lisa Doggett

A memoir of triumph in the face of a terrifying diagnosis, Up the Down Escalator recounts Dr. Lisa Doggett’s startling shift from doctor to patient, as she learns to live with multiple sclerosis while running a clinic for uninsured patients in central Austin. Recounting before and after the discovery of her MS, she chronicles vexing symptoms while trying to be an attentive mother, wife, and a caring family doctor.

Facing the prospect of a career-ending disability as she adjusts to life with multiple sclerosis, Dr. Lisa Doggett is forced to deal with a new level of uncertainty and vulnerability, and the everyday fear that something new will go wrong. Taking off her white coat—becoming a patient herself—she confronts unimaginable fears, copes with her limitations, and sidesteps her skepticism of alternative medicine to seek help from unlikely sources. Drawing on riveting patient stories, Doggett reveals the dark realities of the dysfunctional U.S. healthcare system, made all the more stark when she becomes the one seeking care.

MS pushes Doggett—a perfectionist at heart—to soften her inner drill sergeant and embrace self-compassion. As a patient, she learns to advocate for herself to ensure on-time medication deliveries and satisfactory treatment plans; to navigate chronic dizziness, relapses, and parenting frustrations; and to push her physical limits as a runner to go farther than ever before. As the director of a health clinic for the uninsured, Doggett’s MS inspires an even deeper empathy as she confronts challenging cases, prompting her to work harder on behalf of those in her care, many of whom struggle with illnesses more serious than her own.

This hopeful and uplifting book will encourage those living with chronic disease, and those supporting them, to power forward with courage and grace. It will spark conversations to redefine perfect parenting and trigger uncomfortable discussions and outrage about the vicious inequalities of health care in the U.S. Most of all, it will inspire readers to embrace the gifts of an imperfect life and look for silver linings, despite life’s detours that sabotage plans and take them off their expected paths.

• Language: English
• Publisher: Health Communications Inc EB
• Release date: Aug 15, 2023
• ISBN: 9780757324871

Lisa Doggett

Lisa Doggett, MD, is a family physician, MS Warrior, and co-founder of Texas Physicians for Social Responsibility. She previously directed a safety net clinic in Austin, Texas where she saw an eclectic mix of patients struggling with their own health challenges in a deeply dysfunctional system. A self-described health nut, Lisa was shocked to become a patient herself when she was diagnosed with multiple sclerosis, a bizarre neurologic disease known to be a leading cause of disability in young adults. Since her MS diagnosis in 2009, she has battled frustrating symptoms and insurance companies. She has experienced relapses and has explored alternative treatments. But she has also run two marathons, traveled to five continents, raised two daughters, and embraced her job as a lead physician creating innovative programs for people with chronic disease around the country. Lisa graduated from Baylor College of Medicine and the University of Texas School of Public Health. She has published in the New York Times, Motherwell, and the Austin American-Statesman. She is a columnist for Public Health Watch and blogs for the National MS Society’s Momentum magazine. Lisa has been featured in Parents magazine, Women’s World, and on CBS Sunday Morning. As a national thought leader and 2021-22 Vaccine Science Fellow with the American Academy of Family Physicians, she provides webinars, speaks at conferences, and contributes to articles on a variety of health topics, including stories in U.S. News and World Report, Reader’s Digest, and Healthline. She lives in Austin, Texas with her husband Don, a hospital-based pediatrician, and their two daughters, Ella and Clara.

Book preview

CHAPTER 1

Mr. Sloane

February 1997

The man’s arms and legs were shrunken, atrophied from disuse. His hands were twisted and stiff, curled into rigid fists. He moaned on the long, white stretcher. I stood in the corner, shifting my gaze to the window, the lights in the parking lot, and the dark sky beyond. He used to be a soldier.

This is a fifty-six-year-old white male with a history of multiple sclerosis and hypertension, the second-year surgery resident said. He developed acute, lower abdominal pain earlier today associated with vomiting. Exam reveals abdominal distension and diffuse tenderness to palpation.

Okay, so what’s your diagnosis? Matt, the senior resident, asked.

Well, obviously intestinal obstruction, uh, probably volvulus.

Sounds like it, Matt exclaimed, his voice eager at the prospect of operating.

Volvulus—an abnormal twisting of the intestine back on itself—can cause a logjam in the abdomen. The obstruction blocks the passage of waste products and can cause severe tissue damage, infection, and death. It’s a bread-and-butter diagnosis in general surgery, but in the weeks since starting my required surgery rotation at the Veterans Affairs Hospital in Houston, I’d only read about it in my medical school textbook.

Oh, God, please help! our patient cried out.

Yeah, hey, can we get him some more morphine? Matt ordered a nurse nearby. Then he turned to me. Did you examine this guy?

I recoiled at the thought. An exam would hurt, and this learning opportunity for me didn’t seem worth the price of further pain. But I knew better than to question the rigid chain of command that framed my medical education.

Hi, Mr. Sloane, I whispered, gently touching the man’s shoulder. I’m Lisa, one of the medical students. I’m so sorry you’re hurting. We just need to check your belly once more.

He moaned again, but he rolled onto his back to allow me to examine him.

The nurse is getting more pain meds right now, I said, helping to readjust his sheet and blanket, trying to keep most of him covered as I exposed the parts I needed to assess.

Come on, the second-year resident interrupted. We’ve gotta get this guy to radiology.

Sorry, Mr. Sloane. I placed my stethoscope over the patient’s abdomen, listening for the familiar little squeaks and gurgles that indicate a healthy and active intestinal system. Nothing. I pushed down slightly, pulling back my hand as his abdomen tightened. He winced.

Absent bowel sounds, I said to the resident. And he has guarding.

Even I could tell Mr. Sloane had an obstruction.

But the resident wasn’t listening.

Come on… hustle, hustle, he said, waving his arms as if to push me aside. He grabbed the metal sidebar of the stretcher and pushed it up into place.

I jumped out of the way, thankful to see the nurse injecting more morphine into Mr. Sloane’s IV. Within seconds, he relaxed a little.

Sneaking a glance at my watch, I calculated the hours I had been at the hospital: almost eighteen. Every one of my bones, muscles, and ligaments was tired. Calcaneus, talus, navicular, cuboid… I had learned all the bones in the foot, and each of them screamed for a break. My day had started at 6:00 AM with hospital rounds. After visiting the four patients assigned to me and writing short notes, I had trotted behind the surgery residents as we stopped by to check on patients under the care of our team: Mr. Rossi had been delirious overnight and pulled out his IV. Mr. Peterson was asking for more pain medicines. Mr. Visiago’s wound was healing well, and he might go home.

A morning conference about the management of pancreatitis allowed me to sit for thirty minutes, but I spent hours standing after that, watching two hernia repairs, a splenectomy, and a longer vascular bypass procedure to improve blood flow to an ischemic (oxygen-deprived) foot. Lunch was pizza in the break room, gulped down between surgeries. Dinner—at 9:00 PM—was cold pizza left over from lunch. The day was endless, and I was tired. Tired of standing in place, watching as bodies were cut open and blood suctioned. Tired of the stale air polluted by the smell of burning flesh from the cautery pen. Tired of beeping IV poles and dirty jokes.

I was also ashamed. Mr. Sloane was suffering. He was in the hospital, without any family, being poked and prodded a few extra times for the benefit of my education. He felt like his insides were exploding, yet I was bemoaning my sore legs and inevitable sleep deprivation. How self-absorbed of me.

I was also trying to impress the more senior members of my team. I was programmed to seek their approval. I had always been driven to work hard and study hard, but medical school had humbled me. It wasn’t so easy to excel here. Even if I could cope with the long hours and respect the strict hierarchy, there was just so much to learn.

During operations, the residents would grill me on my knowledge of anatomy—never my strong suit—and laugh in my surgically masked face if I didn’t answer correctly.

What’s this artery? the resident would ask, lifting a thin pink cord with the tiny laparoscopic tool during a gallbladder surgery, his harsh voice muffled.

The hepatic artery? I’d guess.

God, no! It’s the anterior branch of the cystic artery. Remember Calot’s triangle? How many times have we gone over this?

I wasn’t used to being incompetent. But no matter how many times I reviewed the illustrations in my textbook, I had trouble identifying the arteries, veins, and other anatomic structures during an operation. There was no glue in my brain for the intricate details of human anatomy.

I trailed behind as a hospital orderly wheeled the stretcher to the radiology department. When the elevator door opened to the basement hallway, the second-year resident bounded out, followed by the attendant with the stretcher and finally me, marveling at the resident’s enthusiasm and trying to ignore every impulse to slouch to the floor.

At the end of a short corridor, we turned into a room about the same size as a standard patient room, except with a large x-ray machine instead of a hospital bed. The machine loomed over a metal table covered with a white pad and sheet and illuminated by the glare of fluorescent lights. It was nearly midnight.

White and gray, I thought. Except for the sea-foam scrubs and the blue surgical gowns we wore, the hospital was devoid of color, almost like an old movie. Blood was the other exception.

So, is there a connection between this guy’s MS and volvulus? the second-year resident asked me while the techs started preparing Mr. Sloane for a barium enema.

Yes? I answered, hoping I was right.

Correct. MS increases his risk. And what are the other risk factors?

I didn’t know. Uh, older age? Older age is a risk factor for nearly everything; it was a calculated guess.

The resident nodded. Older age, chronic constipation, laxative abuse, other neurologic and psychiatric conditions, he recited. He must have memorized the textbook.

So, we’re gonna do the enema procedure first to confirm the diagnosis, he said. Sometimes that’ll straighten out the twisted intestine, but the patient will almost certainly need surgery after that to keep it from happening again. He may bleed. Then we’ll definitely have to operate.

Mr. Sloane shouted out once more in pain, as the orderlies moved him onto the thin pad on top of the metal table. He was tangled in the bed linens, and I could see his boney spine through the sheet. His suffering was acute and heavy. Intrigued and repelled, I wanted to comfort him, and I wanted to run from the room. But I was an obedient student, and I waited. The enema would confirm volvulus. If the patient agreed, we would operate. If all went as planned, we would return him to his usual state of health or, in his case, to his usual state of severe, chronic, painful suffering. Even if we fixed the obstruction, there was no cure for his MS.

I stood nearby, watching as this broken man was helped into a fetal-like position while a tube was inserted into his rectum. I imagined that once, decades before, he was young and vibrant. Maybe he liked the Doors and played basketball. Maybe he built houses or worked in a restaurant. Then he went to Vietnam. Did he leave behind a girlfriend, or a young wife and child who celebrated his return? I thought of him coming home, with big hopes for his future, only to have his plans sabotaged by MS, to have his body forsake him.

My life had been sheltered before this surgery rotation. I had been spared such sights, such intimate connection with misery. Growing up in Austin, I lived with my parents and sister in a two-story house with a front yard big enough for Slip ’N Slides and games of freeze tag. My grandparents lived two miles away, and we visited every weekend. Everyone was healthy; we liked each other and got along. No car accidents, violent fights, surprise cancer diagnoses.

I felt an urge to talk to Don, my boyfriend since college and a fellow medical student. I wanted to tell him about Mr. Sloane’s case, to process this random cruelty. I wanted his help to understand this terrible disease that destroyed a man’s life and left him with a potentially fatal surgical condition. I wanted his reassurance: Mr. Sloane’s condition was rare. Maybe he would be okay. Don also might remind me that we had chosen to be doctors to help people, and we were learning how to do just that.

But it was too late to call. Don would be asleep.

When Mr. Sloane’s procedure was over, I returned to the break room, picked up my textbook, and settled down on an ancient couch to read about volvulus.

I don’t remember if I bid good night to Mr. Sloane, but I can imagine slipping by his room a little later, after I finally was sent to the call room for a couple hours of precious sleep before morning rounds. He was the first patient I had seen not only with volvulus but MS: the instigator of his abdominal obstruction and the cause of his devastating decline. I would have been relieved to see him sleeping, despite the glare of the vital signs monitor. I hope you don’t bleed. I hope you don’t need surgery, I might have whispered. You’ve been through enough.

CHAPTER 2

Caring for Our Own

October 2009

I looked down at the intake form and the reason for this new patient’s visit to the clinic near downtown Austin where I served as director: electrocution.

Mauricio was a recent Mexican immigrant in his early fifties. He had sustained severe electrical burns over 40 percent of his body while repairing high-voltage power lines. After a two-month hospitalization, he was now home but uninsured and unable to work, walk, or even speak normally. As I collected a basic medical history, I noticed the worn cuffs of his shirt sleeves, the stains on his wife’s faded pink dress. This family was struggling.

"Doctora, he’s in pain all the time," Mauricio’s wife said in Spanish, holding back tears.

Mauricio mumbled something that I couldn’t understand.

What’s that? I asked, leaning closer to his wheelchair.

"Me duele, y no puedo dormir," he said more clearly. (I hurt, and I can’t sleep.)

I could only imagine. His right forearm and the side of his neck were scarred, discolored from the burns. I didn’t know how I could possibly help.

It’s good you’re here, I said in passable but imperfect Spanish. I wanted him to feel welcome, even if there wasn’t much I could do. What’s bothering you the most today?

My legs and back, Mauricio answered. His dark hair was streaked with gray. He sat almost motionless, staring at the floor.

And he has diabetes, his wife added. His sugars are always high.

I met her timid gaze, noting her sad brown eyes, her dark hair pulled back in a low bun at the nape of her neck. I nodded. Okay, well, I think I can help you with that. If nothing else, at least I knew how to take care of diabetes.

Mauricio had been discharged from the hospital three weeks before with almost no plan for follow-up care. He and his wife had been all over the city trying to find a doctor who could see him without insurance. He’d been in and out of the emergency room and was receiving bills for tens of thousands of dollars, which he could never pay. Finally, they had landed at our small family medicine clinic. We charged patients on a sliding scale, but most of our funding came from a local university, grants from the state, local foundations, and a partnership with the city’s community clinic system. We were there to care for patients like Mauricio, who had run out of other options.

Do you have family that can help you? I asked.

Our son lives in California. The rest are in Mexico, his wife said.

What about friends, a church? I asked.

No, she said, looking away.

What about the burn clinic? Can you go back there? I asked.

"Sí, Mauricio’s wife said, we have an appointment there next week."

Thank God.

But they only give medicines for his pain and check his burns, she added. They don’t help with anything else.

My physical exam was limited by Mauricio’s mobility constraints, but I got a sense of the damage. Both legs and one arm had been badly burned. He had received multiple skin grafts that appeared to be healing well, but the nerve damage that left him partially paralyzed was probably irreversible.

Have you applied for disability? I asked.

We don’t have documents. Mauricio’s wife looked away, embarrassed. She meant that they were in the country illegally, a situation I was used to, and one that limited our options further.

What about workers’ comp? I asked.

No, he didn’t work for a company, Mauricio’s wife said.

I gathered that he was some sort of contractor, though I never figured out how or why he was working on high-voltage power lines. A lot of my patients were like Mauricio. They cobbled together a living from odd jobs in construction or landscaping or whatever else came their way via the unofficial day-labor spot in front of the Home Depot. It was a hard way to pay the bills, and it left them vulnerable to all manner of accidents, cruel employers who withheld wages, and landlords who refused to fix broken pipes or get rid of rats. Most were Hispanic, like Mauricio—doubly challenged by language barriers and almost certainly racism, sometimes oblique, sometimes more overt.

Let’s start by getting some lab work, I said. We can do that today. I also want to get the records from the hospital and the burn clinic. We can also check into options for physical therapy… but it may be expensive.

I turned to walk out of the room but stopped, struck again by the immense sadness and hopelessness of the situation. A tiny blunder, a miscalculation, and a life was ruined. I turned and went back to Mauricio, squatting down next to him, placing my hand on the cold sidebar of the wheelchair. I felt a little awkward and uncomfortable, but I couldn’t walk out without saying something more, wholly inadequate as it would be. I am so sorry this happened to you. I stood up again, putting a hand on his wife’s arm. I’m sorry.

---

After seven years of work as a family physician for people without private insurance, I was accustomed to tragedy. The protective bubble of my childhood had been popped long before, during my grueling medical training. Bat-infested apartments, deported spouses, runaway children, and freak accidents were all part of a day’s work. Mental illness and chronic disease were endemic.

Health insurance was unattainable for many of my patients. Eligibility for Medicaid, a joint federal and state program that provides health coverage to some people with low incomes, was more restricted in Texas than in many other states. Nonpregnant adults didn’t (and still don’t) qualify, unless they were disabled or had children and very low incomes. The Affordable Care Act, passed in 2010, with most major provisions phased in by 2014, extended coverage to millions of people, dropping the uninsured rate in the United States among nonelderly individuals from 17.8 percent in 2010 to 10.2 percent in 2021.¹

But even had it existed earlier, it wouldn’t have helped many of my patients, given Texas’s failure to expand Medicaid coverage to adults who earn up to 138 percent of the federal poverty level. To those like Mauricio, who were undocumented, health insurance was completely out of reach.

Being uninsured was—and still is—a risk factor for poor health outcomes. Compared to those with health coverage, people without insurance have more fragmented medical care and lower rates of preventive screening tests. They are significantly more likely to die early. A 2012 report by Families USA stated that between 2005 and 2010, the number of premature deaths each year due to a lack of health coverage rose from 20,350 to 26,100.²

Such disparities were compounded years later by the global pandemic. A 2022 study estimated that, had it existed, universal health care from the beginning of the pandemic until mid-March 2022 could have prevented over 338,000 deaths from COVID.³

Some of our patients qualified for the city’s Medical Access Program—a sort of health insurance alternative for those below a certain income threshold. But many had to pay for much or all of their health care costs. While our clinic didn’t turn anyone away based on ability to pay, our patients struggled to afford their medications and access specialty care. In other words, they could see me for free, if necessary, but if they needed anything else—radiology services, medicines, referrals to other doctors—they often had to foot the bill.

In the years since I had begun working in community clinics, I’d learned to navigate the highways, side streets, and dark, crooked alleyways of Austin’s health care system. There were sharp turns and frequent dead ends. Still, I knew the discount pharmacies and the ones that overcharged. I could rattle off long lists of generic medicines that I favored over the expensive new drugs preferred by physicians in private practice. I also had a mental Rolodex of specialty doctors I could call for favors: the dermatologist who would review pictures of rashes by e-mail, the gastroenterologist who would give me advice over the phone for patients with cirrhosis of the liver, the hand surgeon who would see my patients for free.

Despite my familiarity with the underground network of supports for people without insurance, I had been an unlikely candidate for the job of clinic director. Two years before, when I interviewed for the position, I was pregnant with my second child, and I already had a toddler at home who served as a fine distraction from work, from everything. I had practiced for five years at a similar clinic for uninsured patients, but I had no management experience, no clue how to hire staff, review budgets, or do performance evaluations. As for running a medical practice, especially a new clinic with no infrastructure and unreliable funding—let’s just say it was a reach. But when several other more suitable applicants turned down the director position, I got the job by default, in spite of my deficiencies. I was thrilled—and scared that I couldn’t live up to the task. My family congratulated me. My dad, a U.S. Congressman, was proud. I was adding to our legacy of public service. Only looking back did I realize there may have been a reason—many reasons—why no one else wanted that job.

Be careful what you wish for.

The learning curve at the clinic had been more than steep; it was practically vertical. I marveled that I still had the job two years later. I was now supported by a competent team of committed, mission-driven women. My nurse and office manager, Kim, had a bad-ass toughness and eye for detail. Half Korean and half white, she had learned Spanish and spent much of her day on the phone, communicating in whichever language was needed, with patients in crisis or chasing down medical records from various hospitals. Sara Maria, originally from South Texas, was a skilled bilingual medical assistant who sometimes guessed a patient’s diagnosis before I did. Terri, a wondrous nurse practitioner, shared an office with me. Well loved by patients and colleagues, Terri—a slim, white woman twenty years my senior—worked harder than anyone. She also laughed at my jokes and could coax me out of grumpy moods that I sometimes brought to work. Other staff included a part-time endocrinologist, women’s health nurse practitioner, receptionist, and other medical assistants. Two years after assuming the monumental task of directing the clinic, I alternated between pride in what I’d built and terror that at any second it could collapse.

Like Mauricio, my next patient, Faith, was ready to challenge my resourcefulness and creative problem-solving skills.

I’m so sorry, Dr. Doggett, but I couldn’t get the chest x-ray, she said before I could greet her.

Oh? What happened? I asked, settling on my stool near her chair. I knew Faith well by now. Due to the severity of her asthma, we had seen each other often over the last several months.

The hospital says I owe them six hundred dollars from the last set of x-rays I had for my knees, she explained. I can’t get the chest x-ray until I pay for the knee x-rays.

Six hundred dollars? That’s ridiculous. I would think they should have cost about sixty or seventy dollars—definitely less than a hundred.

No. I’ve got the letter right here.

She handed me a crumbled piece of paper, confirming the price: $623.

I sighed and looked at her. This is totally unreasonable, ridiculous.

Faith’s lack of insurance was the problem. The hospital was inflating her bill, with no regard to her financial situation. As an individual, she didn’t have the clout to negotiate lower rates like an insurance company, which could arrange for steep discounts.

Faith wasn’t alone—nor has the situation improved. A Wall Street Journal analysis published in 2021 showed that hospitals often charge uninsured patients the highest prices. Across 1,166 hospitals included in the report, for example, the fees for uninsured patients were 3.6 times higher than the average rates paid by health plans covering people enrolled in Medicare Advantage.⁴

Faith had gone to the public hospital, presumably her best and cheapest option, but they were still ripping her off.

What should I do? I can’t pay this bill, she said.

Let me make a copy of that, and we’ll give them a call, I said. How are you doing other than that?

To my relief, Faith told me her asthma was better. Kim had helped find a discount pharmacy where she had refilled her inhalers. Her knee pain had improved as well.

I adored this patient and felt tremendous sympathy for her. In addition to early-onset arthritis and thyroid problems, Faith had the worst asthma I’d ever seen. Because her asthma limited her activities and required oral as well as inhaled steroids, she continued to gain weight, restricting her further. She was forty years old and a nonsmoker, yet every breath was an effort. Even on her good days, Faith wheezed and struggled. Getting out of a chair, lying down, getting dressed—everything was exhausting and exceedingly difficult. She needed to be examined by a specialist at the public hospital’s asthma clinic, but they wouldn’t see her until she had another chest x-ray. Even with the chest x-ray, she’d have to wait months for her appointment.

I listened to her lungs, which sounded better than usual, though still noisy with scattered wheezes. We talked again about weight-loss strategies, and I refilled two of her medicines. I made myself a note to call the hospital and follow up with her later. I would have to pour precious minutes, maybe hours, into her case to confirm my suspicions about the expensive x-rays, and I would need more time to search for resources for Mauricio.

I resented the fact that I wouldn’t get credit for any of this time from our funders or clinic administrators, who tallied and averaged the numbers of patient visits each day to assess my productivity, pressuring me to fit in more and more visits. And I resented our fee-for-service health care system that valued quantity over quality, and procedures—biopsies, surgeries, colonoscopies—over face-to-face time and the thinking part of medicine.

Most of all, I was enraged by the endless barriers that kept Faith, Mauricio, and so many others from ever getting healthy. My home state of Texas ranked dead last in the United States for the number of residents covered by health insurance. We had impressive highways, NASA, the biggest rodeo, and the tallest capitol building. We had no state income tax. In Houston, we had the largest medical center in the world, where I went to medical school. Yet we failed to care for our own.

I couldn’t dwell on these injustices or on Faith. I had to move on. As usual, I was falling behind.

My next two patients were pleasant women, both in their fifties, chatty and friendly, both with diabetes and high blood pressure. I made minor adjustments in their medication regimens, discussing back pain with one and vague muscle aches with the other.

My fifth patient was a no-show. Our patient population was notorious for failing to keep appointments. The reasons ranged from lack of childcare or transportation to family obligations to an unaccommodating boss to sometimes just plain forgetting. It was unfortunate, but they were pulled in so many directions. Personal health care just wasn’t the top priority.

Still, that uncertainty added to everyone’s stress at the clinic. We would schedule a manageable number of patients for the morning, and then only three would show up. So we would add more slots, and the next day everyone would show up, and the first three patients would be depressed men with testicular pain and six other problems each. That afternoon I was thankful for the no-show because I was almost an hour behind and needed to catch up. But it meant one less visit on our monthly tally. We were continuing to fall short of productivity expectations, since we were unable to see as many patients as our funders and partners expected. The number of patient visits was the most important measure of our worth—more important than what was accomplished during those visits, patient satisfaction, health outcomes, or anything else. Our failure jeopardized our funding and the clinic’s very existence.

Always on the lookout for ways to care for our patients while keeping an eye on our productivity goals, Kim, Sara Maria, and I tried to restrict each patient to just one or two problems. What is the main reason you’re here today? Sara Maria would ask when bringing someone back to the exam room. If the patient listed multiple complaints, Sara Maria would offer to schedule a future appointment to address issues of lower priority. But despite her attempt to focus my next visit on one or two concerns, the patient, Connie, had insisted we discuss her breathing difficulties, leg pain, headaches, insomnia, and nausea.

I had seen Connie three or four times before. A white woman in her early sixties, she had never finished high school, dropping out, perhaps, to care for a sick family member or help cover the rent by getting a job. Twice divorced, she now lived alone. She was crying when I entered the room.

Hey, I said, suppressing a cough. The room smelled of smoke. She hadn’t been able to quit. What’s going on?

I can’t… my son… my son is in prison, she managed, brushing away dark hair, revealing smeared mascara around her eyes. Blue eyes. Her eyes were blue like mine.

Oh, Connie… My mind bolted, imagining a child in prison. Frustration and disappointment, the constant fear for his safety, a stark cell with no privacy, no beauty. I needed to stay on task and keep Connie focused. One of us had to keep it together. I decided not to ask for any details but to try to steer her back to the medical appointment.

I’m so sorry. It makes it hard to take care of yourself when you’re dealing with a stressful situation like that, I said. It felt like such a pat thing to say, but I had to move on to the real reasons for her visit. How are things going with your breathing?

I had concluded after her first visit that the asthma she described was more likely chronic obstructive pulmonary disease (COPD), which resulted from her smoking. The diseases are similar, but treatments differ. Either way she needed to lay off the cigarettes. Easier said than done.

I’m not doing so good.

Did you start the new inhaler we talked about last time?

Yes, but it made my leg hurt, so I stopped. I’m using that other one now, she said, having calmed down a bit. She pulled out a tissue from a denim handbag and wiped the mascara from under her eyes.

The albuterol? I asked, referring to the inhaler we use on an as-needed basis for people with asthma and COPD.

I think so.

How often are you needing it? I asked. I was trying to determine if she really needed the other inhaler, a daily controller, to reduce her symptoms.