The true meaning of "Presents Well" in medicine

It’s to my detriment and chagrin… and perhaps will even to be written upon my tombstone, “patient presents well.”

My early childhood trauma was caused by numerous hospitalizations. And this was before I had the words to process the pain that triggered combative tantrums. It was my way to communicate the terror I’d internalized at my treatment by doctors, and nurses, and even at the odor of isopropyl alcohol. That was my truth in that time of “Children should be seen and not heard.”

I was not heard, and so I internalized the angst, creating my own survivalist credo: You must not be sick. If you are sick, you are unworthy and will be abandoned. It fit well with the Puritan ethic so prominent in our society or the contemporary evocation to, “Just suck it up.”

Over twenty years, I endured a fear-laced marriage of, I confess, my own design. My credo magnified the need to “present well” (in order to not be abandoned), and it caused me to abandon the truth repeatedly. I traded physical and emotional pain for what I saw as acceptance and security, but what was in reality, isolation, and a reinforcement of my own false narrative, the self-detrimental credo.

Ignorance played a key role (as I was just 19 years old when I married), and coupled with the internalized and ingrained fear, I unwittingly managed to created neuropathways that made my self-preservation credo my “go-to” and default system of coping with stressors. In other words, I became adept at lying to myself and others… I learned to “present well.”

At the urging of my therapist, as well as a number of friends and family members, I recently found myself at the admittance desk at the emergency department. After returning home, later that evening, I recognized that half a century of practice, of reinforcing a facade of acceptable normalcy, created in me this innate urgency and ability to “subject-change.”

Although I presented quite authentically as suicidal (having been admitted to a psych ward for 9-days with the same symptom cluster only a month before), after sitting in the treatment area for five hours and being told it could be another 16 to 36 hours before I would be admitted, I grew weary and panicky. My default kicked in, and escape seemed the optimum choice. My “subject-changing” ability allowed me to redirect conversations with an approach, both subtle and chameleon-like. Before too long, I am sure the ER doctor would note that ‘the patient presents well.’

It is the essence of any marketing strategy, the more willing and hungry the inquisitor or audience to buy a magic story; a story with a happy (or at least “placid”) ending, a story that appeals to their personal sensibility and values… the easier the pitch and the buy-in; the easier the “sale.”

I’ve said of myself for ages, even though I come from a long line of successful sales-folk, I cannot sell something I don’t believe in, that I don’t use myself and cannot personally endorse. The truth (and consequences of withholding it), I’ve discovered, has a value beyond worldly compensation; and the power of the biblical two-edged sword. That said, I also know well, the influential power of good storytelling. It’s the foundation of cultures, and, through this art, we identify ourselves, and each other, and establish communion.

Rather than an unsettling reaction to the change-of-subject akin to an earthquake caused by Tectonic plates shifting, my evolved approach is one that entreats the listener to personally experience the introduction of redirection with all the subtlety of the change of seasons; with the familiarity (if not nostalgia) which affords a momentary respite in the midst of a challenging topic of conversation; an invitation to avoid the hard topics which present massive emotional boulders.

Such emotionally charged topics can stymie even those who often must traverse this inquisitors’ or therapists’ terrain and trip up the less experienced and less watchful. This “course-correction” allows aversion, for the moment, of the hard questions of self-harm and intent, triggers of both the psychological and munitions-kind, caustic conversations and substances, poison pens and products, falls from grace and from high places, dangling conversations and the nuances of a noose.

So, as I sat upright on a wilted gurney-foam mattress in my freshly laundered scrubs, whether by intentional subterfuge or rout, I cast my rather well-hooked line with ease and anticipation, awaiting the strike with each “care team” encounter. Whether it was puppies or babies, the green of the Northwest, or even the more political… (such as the urgency to more fully fund health systems without disparity), the emotional bait was set. Not one listener realized their clinical objectivity had been compromised, as they were readily hooked, with bated breath, by their own assumptive, “the patient presents well.”

There were no more discussions of triggers and means, stressors, and plans. The clinicians seemed to find rare solace in that the “patient presents well,” as, at that moment, the shroud of normalcy allowed them a respite from the wearying responsibility of judging what was normal and what was not; who is an obvious danger to themselves and others…. and who, in the wisdom of Almighty scientific assumptive-ism, is a prize to safely “catch and release.”

In the aftermath of this buy-in is the potential reckoning, reflection, and re-examination. It is the neighbors interviewed on the evening news who recalls, “Mostly quiet. Kept to themselves, really. Nice people.” It’s froth with blaming and shrugging, if not verbal, assaults on the victim for not being forthcoming. Nevertheless, “presenting well,” in and of itself, is both systemically reinforced by the fearful ineptitude of social convention-based intervention and driven by the unconscious adaptation for survival in those who think just a little differently.

Though challenging and burdensome, if not totally foreign, it’s essential for the sake of true efficacy and safety to refuse this ruse of the sales force of clients or would-be clients who “present well,” and for clinicians to become truly insightful, patient, and literally life-saving consumers of the truth by refusing to “buy-in” too superficial presentation and manipulative “subject changing,” no matter how well presented, no matter how tempting the lure.

Just as there are Asian companies who flood Western markets with “knock-off” products with superficial “genuine” appearances and appeal to the consumers’ desire to save time, money, or effort, a closer examination of the “knock-off” of normalcy in presentation is vital to avoid being defrauded. More than just looking foolish when the truth comes to light through circumstance, exposure to this knock-off presentation of “presents well,” is usually more tragic than embarrassing.

I realize that presenting well, if not even professionally adept, is my default. It’s as ingrained in my behavior and thought processes as any habit I have acquired, but nevertheless anchored in trauma and a survivalist’s need to avoid vulnerability and possible victimization at any cost.

I know how dangerous, if not insidious, the deception that “presents well” can be. It is less likely that an interviewer not known to me would have the awareness to question the dubious nature of the truth I present, especially when the buy-in allows for the expedience of processing numbers, and turnover is the goal. I know that in 

Saturday night’s experience, my mind was screaming, “Elopement,” as a tumultuous tide of anxiety rushed about inside my gut.

Although at the end of the night, I found a safe sanctuary at home, there was no guarantee of it. 

As I’ve reflected on my engagement with healthcare professionals and their choice to simply send me home with no guarantees or specific contract for safety, I find that not only am I chagrined by the ease of this legitimatize “elopement,” but with a system that takes the word of a self-admitted suicide-risk without any verification by someone who knows them and can vouch for their safety.

I hate to have my veracity challenged, but there are times when my perceptions are skewed to the point of justifying dangerous thoughts, choices, and behaviors. I depend on the expertise of others to fine-tune this thinking and quiet the white noise that manages to drown out common sense. Just as a well-proportioned individual may not be screened for diabetes, because they can skirt the assumptive connection with obesity, that assumption puts the height-weight proportionate individual at greater risk, if only because the “patient presents well.”

The night I was sent home. Other markers in my symptomatic cluster were not addressed, examined, or tested (predominantly, cognitive impairment), but whether it was physical balance/stability, cognition, thought-processing, memory, or speech/thought latencies, I remained symptomatic. In the presence of these other impairments… the risk of a resurgence of suicidal ideation was (at least for me) and still is quite profound. There are REALLY some good tests, both quantitative and qualitative, for these things. 

Therein lays the disparity. A patient presenting with ANY other life-threatening symptom would have their functionality tested, stabilized, and documented prior to discharge.

However, a good presentation or story, apparently, covers a multitude of sins and symptoms. And so, for this storyteller, an epitaph of the “patient presents well,” is not the worst that might be said, it just very well could have been the last.