She is hunched on the exam table when I walk in, cradling her left arm in her right like a broken wing. Her hair russet brown, her skin almost transparent, eyes big and untrusting.
I glance at the intake form. 19 years old. Pregnancies: 0. Here about: Birth control problem.
“Ryan?” I pronounce her name as it is spelled on the form.
She gives a scoffing laugh. “That’s what my mom wanted to call me. She tried to give me a boy’s name.”
“Oh.” I sit in front of her, at eye level. “Well I think it can be pretty when girls have boy’s names. What do you like to be called?”
“Ry-Ann,” she says, placing the emphasis on the second syllable, with a flat “a”. Staring at me as though this should have been obvious.
I blink and continue. “Okay. How can I help you today?”
She points to her left upper arm. “My birth control, there’s something wrong with it. There’s a bump.”
I reach for her thin arm, hold it up at the level of her heart, press the skin gently with my fingers. She has a three-year contraceptive implant—a small, plastic device the size of a matchstick—under her skin. It is smooth and easily palpable. The overlying skin is pale and soft, without any bruising, redness, or swelling, just a well-healed pinpoint scar where the device was inserted with a hollow needle. Normal.
“How long have you had it?” I ask.
“About a year,” she says, watching my hands.
“And where do you see a bump?” Trying to sound open, curious.
She grabs the entire upper arm with her right hand, circling her fingers around it. “I feel it here. I feel them all over. Up here.” She takes my hand in hers, presses my palm into the flesh over her puny bicep, then over the back of the arm. “And down here, all around.” Down the elbow, circling the forearm and wrist. “Do you feel them?”
I ask to see the other side. Holding both arms in my hands, working my way slowly up again from wrist to elbows to armpits, comparing, squeezing gently, then working my fingers deep into the skin. I take my time, close my eyes. Then I say, “Both arms feel exactly the same to me.”
“Because the bumps are on both sides.” Again she sounds exasperated, as though this should be obvious.
“Ah. I see. The bumps are in both sides. So this is not about your implant, per se?” I am an Ob-gyn, and I am beginning to wonder why Ry-Ann came to see me about this particular problem, these “bumps.”
“Well I don’t know. It might be about that. That’s why I came here, to find out what’s wrong.”
She lets her arms fall from my grasp and reaches with both hands for her shoulders, her trapezius muscles. “They’re in my back, too. I have knots, I guess. But they don’t go away when I massage them. I massage and massage and they’re still there. And lymph nodes—is that what they’re called?” She moves her hands to the base of her jaw, her throat. “I can feel them in my neck. Isn’t that a sign of something?”
Again, I reach toward her with the palms of my hands, as gentle and reassuring as I can be. Her skin is clammy. Through the skin of her neck, the pulsing walls of her carotid artery, I can feel her rapid heartbeat. Something about the bones of her jaw, the structures so easily palpable under the skin, reminds me of a baby bird, something small and breakable under my hands. Rolling my fingers in small, deliberate circles, I trace the chain of anterior and posterior chains of cervical lymph nodes, from the base of her skull, behind and in front of her ears, down the sides of her neck, spanning the triangular borders of the sternocleidomastoid muscles. A few small, soft nodes are subtly discernable to me, but I hesitate to tell her this. This is a normal finding in a thin young woman. I shine a light in her throat, her eyes. Nothing.
“The bumps you feel,” I begin, “They’re normal. Human beings are lumpy bumpy animals, some of us more than others. You’re thin and fair-skinned. You’ll be able to see and feel all kinds of things, normal structures. Look.” Taking one of her hands in mine, I show her the back of her other hand, guiding her fingers over its ridges and valleys. “Your tendons, your veins, your bones. These are all normal bumps.”
She recoils, shaking her head, pulling her hands away. “No, they’re not normal. They’re everywhere. They’re—”
“Look,” I say, against my better judgment. Breaking an unwritten rule about the directionality of the doctor-patient relationship, the physical exam, I hold out my hand to her. “Look at me, I have the same bumps. See?” I bend and straighten my fingers, the tendons and veins tightening and popping under the skin. “It’s normal.” But even as I perform for her, I know it is a show for the blind. Nothing I say or do will convince her. This is not about her birth control, her lymph nodes, the “knots” in her back. This is about something else.
I remember my godmother’s advice. They are the doctors, but you are the only expert in your own body. What credibility do I have for this young woman? I will not be able to convince her. And the longer I talk, the less I am able to convince myself. What do I know about her experience, how it feels to live in her body? What expertise do I hold in my touch, my medical knowledge, my fancy anatomical terms?
She cowers, holding her left arm again, limp and crooked, the way she did when I first entered the room. What progress have we made? What are we doing here?
“Ry-Ann,” I say, starting again. “Listen. I understand you’re worried about the bumps. I have to be honest and tell you that I’m not worried about them. But I’m worried about how much they’re worrying you.”
She gives me a quick glance, a momentary shift in her gaze.
I go on. “Would you be willing to talk to someone about the bumps? About your worries about the bumps? Like a therapist? A counselor?”
She says nothing.
“I have a phone number you can call. I think they’ll want to talk to you about this. I think they’ll take you seriously.”
She shakes her head. “No one takes me seriously. They say ‘knots.’ They say, ‘Just massage, massage, they’ll go away.’ But they don’t go away.”
I try again. “I am taking you seriously. I think the therapist will take you seriously. I’m worried about how worried you are.”
“Will you call the number?”
She stares into the corner of the room, kneading the top of her arm in her hand. Rubbing it like it belongs to someone else, some wimpering child, some wounded soldier.