text: "Who's the President?" "Oh, I didn't vote for that guy" answered Mrs. Johnson. It was not an uncommon response from a patient with dementia. They answered the question, but they didn't really answer the question. It's a clever redirect, one that families often overlooked. The disease progression was so subtle they don't notice. But he saw the patients just infrequent enough to pick up on these little clues. Jack made a mental note to revisit the Mini Mental Status Exam at the follow up appointment. "And she is losing weight too, has she told you about that? She's always having diarrhea and not eating." The questions came from the daughter of Mrs. Johnson. The daughter was herself no spring chicken. Jack estimated her to be early sixties, maybe older. It was always tricky navigating family dynamics during the office visit. This was especially true when dealing with a patient in denial of her dementia, or with the patients' family in denial that mom doesn't actually have advanced dementia. In Mrs. Johnson's case, like usual, it was somewhere in the middle. As was often the case, Mrs. Johnson's daughter had not been coming with her to visits in the past, so now she was making up for lost face time with the doctor. "I notice her weight trend, holding pretty stable over the last few visits," Jack said, trying to be respectful of the daughter's concerns and also reassure the patient that she is ok. "And the same for recent lab trends." Something about the daughter was unnerving. Her eyes, piercing through him, or so it felt. Jack had the impression she was judging him, judging his credibility, his ability as a doctor. "She hates me", he told himself. "You always do that," Jack told himself. "Just focus on the patient, give good care." He was always second guessing. He felt like such an imposter. He had been out of residency a few years but still felt like a neophyte, still felt that his patients, or their families, didn't trust him or didn't believe in him. "And she fell," said the daughter. "When did I fall?" Asked Mrs Johnson. And they went back and forth trying to discern exactly when was the fall, exactly if it was indeed a fall or not, and if any injury or consequence resulted. Jack watched and listened, typing in his progress note as best he could, trying to get all the details right. That is how it went at these visits. The family wanted to make sure they told the doctor everything, literally. And usually the comments were peppered like a machine gun. "What did the lab show", immediately followed by "Did you get the notes from the cardiologist?" Jack didn't have time to answer, much less process, the questions and comments. He managed to keep it together pretty well, making his progress note legible, intelligible. "We could get some imaging to follow up on any brain atrophy," he said, immediately kicking himself because he didn't like the way he had phrased it. He always did that, asked questions in a way that got patients riled up and more anxious than they needed to be. "She has atrophy?" asked the daughter, a little panic creeping in. "Did she think you messed up and somehow caused this?" Jack asked himself. "Did you cause this?" Now he would have to spend more time trying to explain that some degree of atrophy is expected in her age, and not abnormal, without coming off as dismissive. It was an art form, one he was sure he would never master. "What side effects will she have?" the daughter asked, interrupting him. She was cutting her eyes at Jack as if to say "and don't be trying to pull a fast one on me." The question of side effects was the bane of his existence, if there was one. What side effects? As if he could predict that. It was exhausting explaining how side effects are rare. Usually the medicine is well tolerated and the patients don't have any problems, but if they do, the most common ones are manageable, like some mild nausea or insomnia. But the drug label will have everything from blindness to vertigo to sudden death by head explosion. He often had to go down the list, defusing problems that were never even going to happen. "Sometimes, with these types of problems with the memory and mood, people can become self conscious. Like, concerned that they won't remember people's names. And that can be embarrassing. So much so that they end up avoiding people altogether because they don't want to be exposed. And that can leave them feeling very isolated". Jack was just talking now, trying to paint a typical picture of depression and dementia. Sometimes he would do this to try to connect with the patient and the family when he felt like the visit wasn't going optimally. Today, the judgement in the daughter's eyes was palpable. Mrs Johnsons eyes appeared to be welling up. Did he hit a nerve? Or was she upset with him? He never really knew if he was helping or making things more difficult on the patient. What would happened with Mrs. Johnson after the visit? Was he stirring things up? He wanted to help, not make matters worse for her. Jack felt like he had covered everything. The clock on his computer showed that he had gone over the allotted time, and he was getting anxious, knowing the next patient would be having to wait on him. Probably they would be angry when he walked in. He didn't mind spending the time with patients, but it was the patient that came after that stressed him. No, they all stressed him. And their families stressed him. He was always stressed. Did the patients know? Could they tell? "You are such a loser," he told himself. Were they aware that he was an imposter, his training was inadequate, he was not getting every detail correct? Did they know he was incompetent? They wrapped up the visit and the nurse escorted the patient and the daughter to the check out window. In the glass, the daughter could see Jack's reflection as he was walking into another room. "I just love that doctor. He is so thorough. He answers all of our questions and gives us his attention and time. He is the smartest, best doctor we have ever had," she told the nurse. Mrs. Johnson nodded in agreement. "The best," she echoed.