A forty-six-year-old man sat on the exam table in my Brookline clinic last Tuesday, in a paper gown that did not fit him, and said: Doc, I just need something for the back. I can't sleep. I can't sit at work. I can't lift my kid.
I asked him when the pain started.
He said: March.
I asked him what else happened in March.
He looked at me for a long second. He said, in a quieter voice: My wife told me she was leaving.
The chart, the one I am supposed to fill out in eight minutes per patient, does not have a box for that. It has a box for L4-L5. It has a box for muscle spasm. It has a box for radiating to the leg. It has, in the structured fields the insurance company will reimburse against, a fairly elegant taxonomy of the spine. It does not have a single field for March was the month his wife told him she was leaving.
I have been a primary care physician in this city for fifteen years. I have written, by my conservative count, somewhere north of four thousand referrals for lumbar MRI. I have, in retrospect, probably written about half of them for something other than what the MRI was going to find.
I want to be precise about what I am claiming, because the claim is uncomfortable.
I am not claiming that male back pain is fake. It is not fake. The disc is real. The spasm is real. The radiation down the leg is real. The man on my exam table cannot lift his kid. That is not a metaphor. That is a six-year-old who is, this week, not getting picked up by his father.
What I am claiming is that the body is, in a meaningful percentage of these men, presenting a true physical symptom that is downstream of an emotional event the man has not yet been given permission, by his culture or by his clinician, to name.
The NIH puts the prevalence of major depression in U.S. men at about six percent in any given year. That is the number on the chart. The actual number, according to the literature on under-recognized male depression — work by Cochran and Rabinowitz, follow-up studies through the 2010s, more recent meta-analyses — is probably twice that. The reason the chart number is half the true number is that men, in disproportionate numbers compared to women, do not present to primary care with the words I am depressed. They present with emotional numbness they describe as I just feel off. They present with insomnia. They present with irritability their wives have started to fear. They present with new alcohol use. And, very often — by my count, the single most common presentation — they present with pain. Back pain. Headaches. GI distress. Chronic fatigue. Sexual dysfunction.
The pain is real. The depression is also real. The chart, designed in 1973 by men who did not have a box for his wife told him she was leaving in March, codes only the first one.
I want to describe a few patients, with details changed and with the kind of composite-building that respects HIPAA.
A fifty-eight-year-old electrician. Came in for chronic right-shoulder pain. Six months of it. The orthopedist had run him through PT, cortisone, and was about to send him to surgery. I asked him what was happening in his life when the shoulder started hurting. He said, with a kind of confused expression, as if I had asked him whether the moon affected it: my mother died in September. The shoulder, on the imaging, did have rotator cuff thinning. So do most men in their late fifties who have done physical work for forty years. The acute pain, however, had started the week after the funeral. We talked about his mother for thirty minutes. He cried, briefly, twice. The shoulder was not better the next morning. It was, eight weeks later, after he had started seeing a grief counselor and had, with my encouragement, called his brother for the first time in a year, almost completely better. The surgery never happened.
A thirty-nine-year-old finance guy. New-onset GI symptoms. Constipation, then diarrhea, then both. A full GI workup found nothing. He came back to me with the lab printouts, frustrated. I asked him, on a hunch, how he was sleeping. He said, I haven't slept properly in eighteen months. I asked what had happened eighteen months ago. He said: my dad got the Alzheimer's diagnosis. He had not, in eighteen months of medical appointments for his gut, mentioned his father. Nobody had asked. The gut, in retrospect, was an enteric nervous system that had been holding eighteen months of anticipatory grief his cortex was refusing to file. He started seeing a therapist. The diarrhea took four months to resolve. The constipation, longer. But it resolved.
A sixty-two-year-old contractor. Erectile dysfunction. Wanted Viagra. Easy script. I asked him, before I wrote it, whether anything had changed in his life. He said, dismissively, nothing, doc, it's just getting old. Then, twenty seconds later, looking at his hands: my company's been failing. We may have to close it. Twenty-eight years. I gave him the Viagra. I also gave him the number for a therapist who works with men in late-career business failure. He filled both prescriptions. Six months later, the company was, in fact, closing, but the ED was gone. I asked him what had changed. He said, with a small private smile: I told my wife I was scared. I had not told anyone, including me, that I was scared. Apparently that part of me was waiting for me to say it.
I could give you forty of these stories. Most primary care doctors, asked privately, could give you their own forty.
What I have learned, the slow way, is that the most clinically useful question I can ask a man on my exam table is not in my training, is not in my EHR, and is not reimbursable.
The question is: what was happening in your life when this pain started?
That question, asked in a calm voice, with eye contact, with the chart closed on my lap so the man understands that the chart is not what I'm filling out right now — that question opens, in roughly half of the men I see for somatic complaints, a window the man did not know he was carrying around.
The other half do not respond to the question. They say nothing. They say I don't know, doc. They look at me like I've asked them what color their car is. With those men I move on. Not every man's back pain is grief. Some men's back pain is a disc. The job is to ask, not to insist.
For the men who do respond — and the proportion is, in my practice, much higher than my training led me to expect — what comes out is, almost without exception, something the man has not said out loud to anyone in months or years. A father dying. A wife leaving. A child diagnosed. A business failing. A friend killed by an overdose. A father who never called back after the last estrangement. A son who came out and the father is now sorting through twenty years of having said the wrong things at the wrong dinner tables. A retirement that has felt, on arrival, more like a vanishing than a reward.
The body has been carrying it. The body knows the story even when the mouth has not been issued the words.
I want to be careful about one thing, because there is a version of this argument that becomes harmful.
I am not, ever, saying to a patient: your pain is in your head. That sentence is a sentence that should be retired from medicine. It is a sentence that has, over the last fifty years, sent thousands of women (in particular) home with undiagnosed autoimmune disease, undiagnosed endometriosis, undiagnosed cardiovascular events, because clinicians used it as a synonym for I am tired of looking.
What I am saying is closer to: your body is telling the truth. Your body is so good at telling the truth that it is telling the truth about more than one thing at once. There is, very probably, a real physical process here that we should address. There may, also, be something your body is carrying for you that we have not yet named together. Both can be true. The treatment, in many cases, includes both.
The men I have seen do best, over my fifteen years, are the men who get this dual framing early. The men who do worst are the men whose somatic symptoms get a long, expensive, single-rail medical workup — MRI, surgery, opioid, injection, second surgery — while the emotional event upstream goes unnamed and unaddressed. The pain, in those men, often migrates. The disc heals; the shoulder starts. The shoulder heals; the gut starts. The body is patient. The body will keep speaking, in different idioms, until it is heard.
If you are a man reading this, and you have a chronic symptom that has been workup-ed and managed for months or years without full resolution, I would encourage you, very gently, to ask yourself the question I now ask my patients:
What was happening in my life when this pain started?
Not around the time. Not the year I started noticing. The specific month. The specific week, if you can reconstruct it. Write it down. See what is there.
If something is there — a death, a loss, an estrangement, a fear, an event you have not told anyone about — that does not mean the pain is fake. It means the pain has a second address. Treat the first address, the physical one, with your medical team. Treat the second address, the emotional one, with a clinician who specializes in it. The script for raising mental health with your primary care doctor may help you start the second conversation, and the PHQ-9 is a free, validated, ninety-second self-screen. If you live in or near Boston, the men's-issues therapist list includes clinicians I have personally referred patients to.
If you are a partner or parent of a man who is, for the first time in his life, dealing with a chronic somatic complaint — and especially if it arrived after a hard life event — the "when he won't go to the doctor" walkthrough has scripts for the first conversation.
The chart does not have a box for it. The body has the whole sentence. The job, if we are doing it right, is to translate between them.
That translation is, in the quiet rooms where it happens — in my exam room, in a therapist's office, at a kitchen table where a wife finally asks the question she has been holding — most of what medicine, at its best, has ever been.
If you've been carrying a symptom for months and want to start the second conversation, the scripts for talking to your doctor about depression and the PHQ-9 screener are both free and private. If the man in your life won't go in, the "when he won't go to the doctor" response is written for the conversation before the appointment. Names and identifying details of patients in this piece have been changed.