Behind the Brow That Furrows

Neha Aggarwal at jamanetwork.com

Growing up as the youngest child, I always sat in the back seat of the car. This was a position enabling infinite wonder. My gaze was unfettered and I could freely observe the world, as I was rarely turned to first for conversation. One sunny Georgia afternoon when I was 13 years old and had assumed my usual position in the back seat on the drive to our weekend outing, my gaze wandered. I saw the teeth of my older sister in the front seat as she vivaciously laughed while chatting with our mother. When the conversation mellowed into peaceful silence, my gaze shifted upward to the oval rearview mirror. I noticed a vertical line etched into the space between my mother’s eyebrows. Her brow was furrowed, and she did not seem to notice it.

I asked, “Mom, what is that line between your eyebrows?” She sighed, touching her brow in detached but slightly self-conscious frustration. She replied, “Do me a favor, and don’t stress about what you cannot control. Don’t inherit this from me.” This crease was a remnant of the stresses she has borne throughout her life. As I gazed solemnly at the line, I imagined what might have happened. Every time that she furrowed her brow, the skin pulled closer together, as if it were embracing itself to protect against the stressor. This continued until the skin could no longer risk being unshielded, choosing instead to remain connected at rest.

I did not fully comprehend her words at the time, so I exhaled my concern and hoped that my innocent question had not bothered her much. Yet I still wondered how raising my sister and me might have contributed to my mother’s stress lines, which she had accepted as a characteristic of her flesh. Would my sister’s laughter in the car have been possible without this mark on our mother’s forehead? Would my serenity in the back seat have been replaced by a different feeling altogether?

Eleven years later, I am a medical student in a maternal-fetal medicine clinic, and I meet you. You are a young single mother of 2 small children, but your presence at this clinic gives you an additional label: our patient. This label subjects you to our sensitive clinical eyes, which are perceptive not to make you feel exposed but so that we do not neglect to notice any detail that might impact your health. Embarking on the task of observation, I call upon my skills from afternoons in the back seat.

As we review the status of your pregnancy, I mentally check off the trimester-appropriate questions I am slated to ask you. I stay in my lane of medical questioning as a clerkship student on her obstetrics and gynecology rotation. However, in the midst of administering the formula-driven clinical questionnaire, I also bear witness to the linear indentations under your eyes. I turn away from the computer on which I was taking notes and angle my feet toward you. I discard the clinical questionnaire to ask what else has been impacting your pregnancy. The lines that were before just passengers on our conversation grow deeper, more consequential and consuming, with each new piece of your life you reveal to me.

I learn of your diagnosis of multiple sclerosis only 2 years ago. I imagine that the disease onset and eventual diagnosis felt utterly unjust. It injured your relationship with your body, which before implied a promise to never surprise you. You share with me how your body’s natural movements have changed, as has the way in which you interact with the world. The knowing look in your eyes testifies to this adjustment.

I see the pressure of motherhood you carry on your shoulders, your burning wish to bear life’s challenges before they can reach your children. I think about the line on my mother’s forehead, a small physical manifestation cluing an observer into her history of decades of struggle to ensure her family’s happiness. Bracing your children from these forces exhausts your energy, collapses the space between your shoulders, and pulls tension between your eyebrows until your skin can no longer stretch.

As you share your testimony of the challenges that multiple sclerosis has introduced to your everyday life, my observations deepen. Your multiple sclerosis establishes itself as the third person in the room, exerting a silent force over me as we interact. I see healing bruises on your legs from falls that came suddenly, irrationally—and, like a needled thread waiting to tighten, my legs tense from ankle to hip. I see laughter lines on your cheeks from watching your little ones growing up, and the corners of my mouth involuntarily rise. These pieces of you are not documented in our medical records, but they convey the silent stories that are woven into your flesh, subconscious but inexplicably alive.

Once I am educated on all this history with which you present, those tension lines never go away, and I see them more profoundly. They represent the challenges you have faced condensed into a small physical detail, easily overlooked if not further explored. The eyes that glimmered when we said hello to each other are now condensed by the skin underneath that bears the weight of the parts of your life to which your clinicians are uniquely privy. You trust us with your story, and we can only half-deliver for you. We cannot fix functional disability you have accumulated from prior relapses; we can only prevent future relapses with disease-modifying therapy. We cannot prescribe your disease-modifying therapy during pregnancy due to risks to the developing fetus. We know in the back of our minds that the smoldering disease course of multiple sclerosis over time exposes disability caused by old brain and spinal cord lesions. Our medicine lives in a world too entropic to capture its goals.

I bring in our attending physician, and we review the medical plan with you. We tell you to please let us know if the disability you notice from multiple sclerosis gets any worse during your current pregnancy or if you suspect a new flare is emerging. In the back of our minds, we consider the careful attention to fetal health involved in treating a flare during pregnancy. We veil our conversation with reassurances concluded from a qualitative estimate that pregnancy is an immunosuppressive state, which reduces the chance of a relapse happening while you are off your disease-modifying therapy. In the back of our minds, we hope the qualitative estimate will apply to you. We discuss routine care for the second trimester of pregnancy. In the back of our minds, we wonder how the guidebook to manage pregnancy would be different if it were tailored to patients with multiple sclerosis.

At the end of your visit, we say you are free to go. You stand and I observe your gait for the first time, as it is not part of routine examination in the obstetrics and gynecology clinic. As you begin to walk, you sway and immediately outstretch your arms, hoping to be steadied by the wall, or the computer, or anything nearby. I offer you my arm, and we walk down the hall together toward the clinic exit. I turn to you and say, “It was very nice to meet you, and please take care.” I try to listen to what you say in response, but all I can see are the lines under your eyes, and I feel my eyebrows furrowing.