The Black Dog

It was a particularly sunny morning, and golden light streamed through the clinic windows. Seated in my preceptor’s office, I scanned her list of patients for the day. As a first-year medical student, I was to do preliminary interviews with some, and I hoped to find a few cases that would offer a chance to test my diagnostic reasoning.

The list held a lot of the usual–medication follow-ups, annual physicals, well-child checks—plus Ernest, a seventy-eight-year-old man who’d come into the emergency room for a urinary-catheter issue. This seemed promising, so I volunteered to see him.

A compact older man, Ernest shuffled in with his walker, the catheter bag swinging with every step. His downcast eyes looked glassy, and his shoulders sagged as if under an invisible burden.

Facing him across the small clinic desk, I felt vaguely uneasy, without quite knowing why. Nonetheless, I launched into my usual introductory speech.

“It’s nice to meet you, Ernest,” I said. “I’m a medical student working with your physician today. If it’s all right, we can chat first before the doctor comes in. How are you doing?”

I offered a smile, which he didn’t return.

“Actually I haven’t met this doctor yet,” he said. “I’m a new patient. After my Foley got clogged, I went to the ER, and they replaced it. I’m just here to follow up.”

Preliminaries over, it was time to get down to business. I picked up my pen, ready to transcribe the pertinent details.

On the desk between us, Ernest gently placed a thick hardcover book, its front dust-jacket flap tucked between two pages.

Not quite sure where this interaction was headed, I shot him an inquiring glance. Something told me that this wasn’t just about a urinary issue. His eyes held an urgent look, as if he couldn’t wait to share something.

As he opened the book, I heard its spine crackle. It’s funny what the brain chooses to remember: I can vividly recall the smell of that crisp paper, and the look in Ernest’s eyes, but not the book’s title.

He pointed to a paragraph.

“Can you please read this?” he said. “It would explain a lot.”

My heart jumped in my chest. I’d been thinking that we were going to talk about pee, and I had my litany of good little medical-student questions lined up in my head, ready to be spit out. But as Ernest opened the book and pointed to the page, my brain came up with a myriad of other scenarios.

Is this going to be some sort of dark confession of a long-ago crime? Is this elderly man about to make an elaborate pass at me with the aid of an inappropriate romance passage? Is he a retired teacher, testing my comprehension and critical-thinking skills before he allows me to play doctor?

Medical school teaches you many things, but improv isn’t one of them. Now fully off script, I dutifully turned my eyes to the page and read.

The passage described a black dog that was like a shadow, always following and quietly watching—a specter that couldn’t be shaken, no matter how fast the author ran or what route they took. The dog was shrouded in a darkness and heaviness that enveloped everything around it with sorrow.

“That’s how I feel,” Ernest said.

There it was. Suddenly I knew why I’d felt so uneasy and uncertain when Ernest first arrived. I was picking up on the subtle physical signals of a man who didn’t quite know how to express himself, but knew that he needed to. I was feeling the presence of the black dog.

As my mental cogs were grinding to put all of this together, our eyes met. His were wet with tears.

Never before had a patient, especially one I’d just met, offered me such an intimate look into their inner world. My face flushed, and a lump rose in my throat. I didn’t know how to respond.

“I’m so sorry you’ve been living with this feeling,” I said finally, afraid of saying the wrong thing.

Ernest’s reserve had evaporated: Now the words tumbled out of his mouth.

“My wife died recently,” he began. “We were married for decades. Afterwards, I lived in our house alone, with no one to help me. I had to move here to live with my sister and her family. It’s hard to be in a new place, and my sister and I aren’t really close. I don’t have many people to talk to.”

He was trying to get used to his new surroundings, he continued, but everything felt off-kilter and unfamiliar. Anxiety and stress and loneliness and a new house and health problems…the black dog.

Although I’d never faced losses like Ernest’s, I still felt a pang of recognition. I too had a black dog in my life.

I’d been an anxious child who grew up into an anxious adult, and medical school had only ratcheted up the intensity. My own black dog was a mix of fear of the unknown and feelings of being an imposter. Ernest’s description of living with anxiety amid so many major life changes resonated with me deeply.

We sat there quietly. I placed my hand on his and pulled the tissue box closer. The tension that had hung in the room had melted away.

“Thank you for sharing your story with me,” I said, hoping that my words were the right ones. “You’ve been through so much, and what you have been feeling is completely understandable. I appreciate your honesty, and I’m so glad you brought this up.”

(Years later, as a fourth-year student, I came to understand Ernest’s grief as well as his anxiety. While interviewing for residency positions, I looked on helplessly as first my grandmother and then my father-in-law entered into end-of-life care and passed away, mere weeks apart. Trying to balance my hopes and dreams for the future with the sadness and grief of the present made me recall Ernest and his struggles with the black dog.)

My preceptor entered the room, and by the end of Ernest’s visit we had a roadmap for treatment aimed at helping him to navigate this new chapter of life. As his tears dried, and new medication and a follow-up appointment were arranged, Ernest seemed a bit brighter and more talkative. He was armed with a plan—but even more importantly, he had shared the burden that had weighed him down for so long.

As he shuffled out the door, I knew that the black dog would continue to follow him. But I felt optimistic that the medications, our conversation and the healing effects of time would help him along the way.

Years later, I often reflect on Ernest. From him, I learned that sometimes the best medicine doesn’t come via a prescription: For Ernest, it was a hand to hold and a listening ear from someone who knew the black dog, too.