Instead, I stood and said, “I’ll be back in a moment. I need to check with my nurse on something.”
Outside the exam room, I leaned against the wall and shut my eyes. There is no way forward. From past experience, I know where this is going. I can’t convince this woman that she does not have Lyme disease. It’s as if logic is irrelevant. She has a belief system, a systematic, comprehensive belief system, which is, at its core, contradictory to my belief system. We belong to different churches. We subscribe to different religions. She won’t convert, because my facts are not enough. Progressive disability is not enough.
I am the establishment. I am playing the role of the Catholic Church in the Dark Ages, and she and Dr. F. are Galileo and Copernicus claiming that the earth orbits around the sun and not the other way around. I represent the status quo; convinced that the Lyme spirochete follows the accepted rules of infection, that it is susceptible to routine courses of antibiotics, and that standard scientific methods can help us unravel the mystery of why some patients with Lyme disease recover and some don’t. Except that there is no great mystery here: Ms. Corinth has psoriatic arthritis and not Lyme disease.
I can bring up the fact that her swollen toe began after antibiotics started. I can explain that her laundry list of symptoms—her progressive pain and disability—is shared by many patients with progressive arthritis. The tremor in my finger resolved. This is not a consult, it is an ecumenical meeting. I can only offer what I can offer. I returned to the exam room.
“Okay, now where were we?”
“We were talking about medications,” Ms. Corinth replied.
“Right. And I assume you’ve had a chance to read more about methotrexate?” I asked.
“I have. And I would never take a drug like methotrexate. Dr. F. has a plan. He’s explained to me that the Lyme infection hides out inside cells. It’s constantly changing and evolving. That’s why I need to bathe my system with combinations of antibiotics, to catch it when it emerges. My immune system has been devastated. We need to build it up with supplements and changes in diet, and you’re asking me to ingest a drug that will tear down my immune system and poison my liver.”
“So then, I guess we’ll need to agree to disagree.” I realized I was no longer actively engaged. I chose my words carefully. “I’m sorry, that so far, your inflammatory arthritis, what I am calling psoriatic arthritis, hasn’t responded to what Dr. F. has prescribed. And if you don’t want to take the kind of medications I suggest, I’ll summarize my thoughts to your primary care doctor and leave the door open to see you in the future. If you change your mind, I can …”
The Patient’s Real Goal
“That’s fine, except for one thing. I need a letter so that I can keep getting the IV antibiotics through my port. That’s all Dr. F. and I need from you. I’ve just started a gluten-free diet, and I think it’s already helping.”
