The
Good Patient

We treat compliance as a virtue, which it sometimes is. It is also a skill, and skills are trained. Nobody is born able to override their own signals in favour of an external instruction. That has to be installed, and it is installed early, and it is installed by making the alternative expensive.

And it took me too long to see this. That their compliance was more often than not a pattern they created for themselves early on to counter feelings of inadequacy, insecurity and shame.

If you were trained to override your own signals in order to be acceptable, and you have spent thirty years getting excellent at it, then handing you a protocol is handing you one more standard to be excellent at. You will execute it beautifully. You will execute it with the same machinery that made you sick.

In Indian households the word is sanskari, and nobody needs it translated.

A girl learns that her value is in being easy. Not loud. Not difficult. Not the one who argues at dinner. She learns to read a room and adjust herself to it before anyone has to ask. She learns to answer the question "are you okay or kaisi hai" (if asked at all) correctly rather than accurately, and she learns this so early that by adulthood she often cannot tell you the difference.

This is not usually done cruelly (and that’s why it lasts so long) It is done with love, by people who believe they are preparing her for a world that will punish her if they do not. And they are frequently right about the world, which is why the training works.

What gets trained out are not her feelings. It is her expression of it. She keeps the whole signal and loses the ability to act on it.

Then she comes to me at thirty four with Hashimoto's, or at forty one with lupus, or with rheumatoid arthritis, or with a diagnosis she was given six years ago and has been managing ever since.

What I can tell you is what I have seen, repeatedly, in my own practice.

The women who arrive with autoimmune conditions are disproportionately the women who cannot tell me what makes them angry. Not the women who have nothing to be angry about. The women who cannot locate it. Ask them directly and you get a pause, then a reframe, then a defence of the person who did it.

Now, as you read this, I can see your argument building and for sure, you should make it: that chronic illness is exhausting, and exhausted people are agreeable. Maybe the illness produced the temperament rather than the other way around. I would take that argument seriously if the agreeableness started with the diagnosis. In these histories it does not. It goes back to childhood, and their mothers were often the same, and they will tell you so with some pride.

Make of that what you like. I am telling you what is in the files.

The men who come to me are a different presentation and, I think, the same mechanism.

They arrive with metabolic and gut complaints. Insulin resistance, visceral fat, fatty liver, a lipid panel their doctor is unhappy about. And a gut that has been wrong for years.

Ask them about stress and they will tell you it is under control. Ask them what they feel and you will often get an analysis instead of an answer. This is not evasion. A lot of them are not withholding anything. There is nothing there to report.

Boys are not trained out of expressing feelings so much as out of having access to it. The vocabulary is not developed. Sensation goes unnamed until it stops being noticed, and a signal you cannot notice is a signal that cannot warn you. I wrote about this in a previous article What gets built instead is competence. A boy is made good by being effective.

Which produces two clinical consequences worth sitting with.

The metabolic side is silent by nature. Insulin resistance does not hurt. Fatty liver does not hurt. Visceral fat does not hurt. In a man with no interoceptive access, there is no early warning at all, and so the first real signal is a number on a page, arriving several years late.

The gut is the exception, and I think it is the exception for a reason. The gut is the loudest channel a body has. It produces symptoms that cannot be reframed as nothing, cannot be pushed through, and cannot be handled with more discipline. When every other route to awareness has been closed, that is the one that stays open.

Here too there is an obvious argument- wealthy, sedentary, frequently travelling Indian men in their forties who drink socially and eat badly have metabolic and gut disease because of the drinking, the travelling, and the eating. No inner mechanism required.

That is largely true, and I would not argue with an endocrinologist about it. Lifestyle explains most of the presentation.

It does not explain the non-responders. It does not explain the man who cleans up everything, executes the protocol without a single deviation, and does not improve. And it does not explain why, when something else finally moves, the same protocol starts working.

Put the two together and the picture is uncomfortable.

A woman is trained to be quiet. A man is trained to be effective. Both are trained into obedience to a standard outside themselves, at the cost of the self that was supposed to be running things.

Then they get sick. And then they are handed a protocol.

Which is another standard outside themselves.

This is why I have stopped reading perfect compliance as a positive sign. Sometimes it means someone is motivated. Sometimes it means the disease has found a patient who will manage it forever without ever confronting the thing underneath it, and everyone involved will describe that as doing well.

I am not going to give you a technique, partly because a technique would become one more thing to execute correctly.

What I see in the people who turn a corner is smaller and less impressive than anything I could sell you.

The woman says the true thing out loud to one person. Usually not the person who deserves to hear it. Usually a smaller thing than the real thing. And her sleep changes that week, which she will tell me about without connecting it to anything.

The man notices one sensation and names it accurately. Not processes it. Names it. And a gut that has not responded to eight months of correct treatment starts responding, which annoys him, because he did the eight months properly and would prefer the credit to go there.

I want to be honest about the price, because most people writing this sort of thing are not.

If you stop being agreeable, it will cost you. Some people in your life liked you agreeable and will not stay for the new version. You may be called difficult, unstable, too much, or unwell. That is not a hypothetical risk and I am not going to pretend it is rare.

So yes, speaking has a cost, and anyone telling you otherwise has not tried it.

Here is the part nobody puts next to it.

Silence also has a cost. It just arrives differently. It comes in slowly, over years, and it is not billed to your reputation. It is billed to your thyroid, your gut, your joints, your sleep, and your forties.

One bill arrives fast and in public. The other arrives late and in private, and you pay it in your body.

Nobody gets to skip both. The only real choice is which one you would rather be paying, and most people never find out they were choosing.