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Every Wednesday, as part of my second-year medical student experience in Rockford, I travel north to see patients at the UIC University Primary Care Clinic at Rockton. Early this past winter, I was handed the chart of a new patient and I was told I was seeing him for “stomachaches.” I closed the door to the sterile white examination room to face a thin, pale young boy, fourteen years old and sitting on the exam table with his knees pulled to his chest. His head jumped as the exam door snapped briskly shut. I introduced myself and crouched at eye-level next to him. He tightened the grip on his knees. “What’s wrong?” Silence filled the bleach-tinged air, and his eyes stared at me, unblinking.

“He’s not eating anything, says his stomach hurts.” The voice came from the mother in the corner of the room. I hadn’t even noticed her as I entered, all my attention focused immediately on the tensed figure on the bed. “For the past two weeks, it’s been nothing but cereal, and only a handful of that.” I listened to the mother sketch a history of nausea, stomachaches, and absent stares. It gave the impression of more than the typical stomachache, and I plied ahead, waiting to finally ask the key question that slipped the knot on this mystery and sent the bacteria or virus or swallowed garden flower culprit plummeting into my lap. The knot refused to give.

“Where did he get the bruises?” I ventured, hoping to unearth some bleeding disorder with a forgotten manifestation of gastrointestinal symptoms. The mother looked at the scattered marks around the red-head’s temples through her friendly librarian glasses, then up at me.

“He’s very active, normally, and gets into all sorts of spots. He comes in from the woods with new cuts and scrapes every night. You should have seen him after the big rains, all mud and torn jeans.” With this she looked back at the alabaster boy huddling on the bed and smiled with the memory of his past spirit.

A professor teaching our physical diagnosis class told us we should know 80 percent of the cases coming before us by hearing the

• descriptive details set the scene and focus on the patient

• first-person point of view

• dialogue provides infor- mation narrator did not know

• Narrator introduces a key conflict into the plot

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Mother uses present and past perfect tenses to refer to earlier actions by her son; narrator uses past tense to describe mother’s actions in the exam room

Jeff Gremmels, “The Clinic”

history alone. This case was quickly proving itself the undesired 20 percent. I moved to the physical exam. The boy was not keen on the concept of my examining him, and made his desires very clear as he refused every request to look up at me or to open his clamped mouth. I wanted to solve this puzzle and began to insist more forcefully until finally, with his surprisingly strong mother, I managed to pull his loose shirt over his head. Beneath that shirt lay pale doughy skin, its spongy texture belying the taut musculature beneath. On the surface of the skin was a continuation of the light bruising around his temples. As the mother sat down and the boy resumed his curled-ball posture, my eyes picked out almost one-dozen small, red “U”s, with two small bars between the uprights like a German umlaut. Raised and bright, more like a rash or burn than a bruise, I hoped these would be the clues I needed to solve my mystery of the afternoon. Further examination revealed nothing more than a continuation of the pattern down to his ankles.

I combed my cloudy memories of past lectures for anything reminiscent of this strange mark as I walked up the hall to find a doctor. The search failed to exhume any diseases with ties to Germanic vowels.

As I explained my cryptic findings to the attending physician, I saw her eyes quickly open, contradicting my belief that she was actually asleep. Pushing insurance papers towards me, she quickly stated, “I’m going to look at him. I want you to have the mother fill these out in the waiting room.” I followed her white lab coat to the exam room and completed my assigned mission. I returned from the waiting room—despite the mother’s distant protests of having already completed the same forms—to find the attending physician on the phone and admitting my patient directly to hospital care.

Twenty-five minutes later, I again sat in her office, listening to the diagnosis. “The wheels of a lighter, a disposable lighter, leave those two umlaut marks—nothing else looks like it. It’s almost always abuse in his age group.” I couldn’t think of any reply, and we spent several minutes gazing into the carpet, silent and introspective.

• Events in exam room presented in chronological order

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transitions increase suspense, then lead to climax of plot

I left the clinic alone and went directly to my apartment, missing the evening lecture on “Insulin and Diabetic Control.”

Four days later, I went to the hospital to see the boy who was once my patient. I read the psychiatrist’s chart notes slowly, rereading the passages describing the boy’s abuse by his stepfather and his three-year history of self-mutilation and depression. It never entered my mind, so avid for a solution, to ask for a history of hospitalizations or illness, and I felt the cavernous shadows of my own missing knowledge hinting at their depth. My focus had always been on the disease, the physiologic atrocity accosting the patient’s unsuspecting organs and cells. This was my first glimpse into an arena I had utterly neglected—the patient’s psyche—quietly present in everyone and in every disease.

Entering the boy’s room, I found him asleep, an IV pole standing sentry over his frail visage. I picked up a crumpled note from the floor, smoothing it to reveal the young patient’s shaky handwriting:

I wish I were a paper airplane, Soaked in gas, shooting red flames, burning with an orange glow, over all the people below. I could fall through the sky like a comet or a meteorite. I could become a UFO, become someone I did not know.

Years of lectures, labs, and research could not match the education I received in five days with this single boy.

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More transi- tions lead to narrator’s final understanding of events

• Narrator’s main point in telling the story

Jeff Gremmels, “The Clinic.” Reprinted by permission of the author.