DRVSS, NLD, the disability I don't officially have

(This is cross-posted from my Livejournal.  I hope that's allowed)

DRVSS 

It’s pronounced, roughly, Diverse, and stands for “Difficulty Responding to Visual Stimuli Syndrome.”

And no, it doesn’t exist.

It was around tenth or eleventh grade that I concocted the term, because that was when I began to notice just how much difficulty I was having dealing with visual stimuli, what I would now call “visual processing.”  Before then I had had difficulty recognizing people (and as a tormented child at a school where “everyone knows everyone” by definition, I had been unable to explain that I couldn’t recognize my tormentors) and difficulty following certain TV programs, but this was the first time it was beginning to impact my academics.

Mostly it was a problem in French class.  We were doing a lot of conversational work preparing for the language AP exam and I was struggling.  One task involved telling the story from a series of cartoon pictures.  I recall not recognizing a lifesaver and thus not realizing the setting was a boat.  Another was a movie-watching assignment where we had no book (unlike movies we’d seen in English class that were based on books we’d already read, or those in History class where we were not expected to have an involved discussion about plot and character.)  In both scenarios I was completely lost, and the teacher mostly unswayed by my plaintive whimper that I “couldn’t do this in English either!”

The one that sticks out the most in  my mind, though, is a scene from US history class.  I had generally been a good history student, and got on well with this particular teacher.  I read the textbook, participated in class and LOVED writing essays.  So when the teacher put some contemporary political cartoons on the overhead and asked me to explain the first one, he was acting in good faith that I’d have a timely, appropriate response.

Instead, I stared at it.  There was silence.

The teacher decided to prompt me, a good pedagogical technique.  “What is the cartoonist trying to say about President Clinton?”  The year was 1993. 

I stared some more, at the three figures sketched.  I had watched the debates on TV, lived with Clinton supporters for the past election cycle.  I knew his voice.  “Which one is he?” I asked.  There were snickers.  The teacher pointed.  I stared some more.

“What does what President Clinton is wearing say about what the cartoonist thinks?” he prompted still further.

“Is he wearing something unusual?”

It was with a good bit of understandable impatience that the teacher said, “Nightengale, he’s wearing a dress!”

Oh.  Well if I had stood there with my eyes closed and been told, “there’s a cartoon with the newly-inaugurated president in a dress, what does that mean?” the whole thing would have been over and done with by now.  I interpreted the cartoon.

This was the first of many times I suspected I would have done better with my eyes closed, if people didn’t think I had 20/20 corrected vision and had to explain things to me verbally.  At that point it was more of an annoyance than anything else.  But it was becoming an issue in the classroom and I decided it needed a name, so I gave it one.  DRVSS. 

I went off to college and took Greek.  I’d always been good at languages.  Latin.  French (cartoons and movies and names of American brands of soda notwithstanding.)  Spanish, for the short time I’d taken it.  So why not Greek?  Well, there was always a point in learning those other languages where the letters formed themselves into words, and then phrases, and then sentences.  Greek stayed as letters I had to sound out.  Everyone else was reading Plato and I was still sounding out words.  Greek and I agreed to walk away slowly before anyone got hurt.

The next year it was organic chemistry.  Everyone always says orgo is a lot of memorization.  Well I’d always been good at memorizing, but here I couldn’t find anything to memorize!  The pictures all looked the same to me.  This time I couldn’t walk away slowly because I needed this course if I ever wanted to attend medical school. 

So I went to get myself tested.  Because, see, by that point I had learned there really is a DRVSS, it just has another name.  NLD, or sometimes NLVD.  Non-verbal learning disability.  NLD has some other aspects, like difficulty interpreting non-verbal social cues, but one of the hallmarks is a relative difficulty interpreting visual, as opposed to verbal input.

They gave me IQ tests and a Rorschach test.  Most of the visual questions on the IQ test were things I could reason through verbally.  Those blocks to rotate in your head, for instance, I had always been good at those because I could just talk my way through them.   I failed the Rorschach.  Oh, don’t tell me you can’t fail it.  I failed it.  There were 20 little cards, and for the first 15 or so, all I could say is that each looked like an inkblot.  Sometimes I prevaricated a bit and said they looked like butterflies, which, with their inkblot symmetry, they did, sort of.  I was told, not without some condensation, that most people my age could see more than one thing in the inkblots.  This infuriated me, since I could barely see one.  Then this one inkblot near the end, it actually DID look like something!  I was ecstatic.  It looked, I said, like an acetabulum.  “A what?” the tester asked.  “An acetabulum,” I said.  “At least I think that’s what it’s called.  It’s a bone in the pelvis.”  In retrospect I would have said it looked like the entire pelvis, acetabulum, ilium and all, but I hadn’t had anatomy at the time.  And I don’t think this explanation would have gone over any better.

In due time I got my results back.  There was a 16 point discrepancy between my visual and performance IQ scores, which was statistically significant and “associated with a non-verbal learning disability” according to the report they gave me.  However, they told me in person this didn’t count as an LD because both scores were above average.  They interpreted my problems with the Rorschach as inflexibility.  Swell.

I took orgo again, found a way to type footnotes to my handwritten diagrams explaining what the differences were between each picture, memorized the footnotes and did well.  My non-NLD was not really a problem for the rest of college, or indeed my years of teaching.  Oh, watching Star Wars or the Princess Bride was a nightmare, until, of course, I was given the book to read, so I either avoided movies, went with a friend to interpret or did my homework during them.  I had a little trouble telling if the kids had cleaned up an area according to specs, and I had a few students I found it difficult to tell apart from time to time, until I learned their voices.  And then, of course, there was the complete lack of any sense of direction, like the night I drove from Delaware to Delaware by way of Maryland twice.  Or the little city of Salisbury Maryland, where I got lost so many times, the wrong turns looked just as familiar to me as the right ones.

But mostly I made it through until medical school.  When I was confronted with anatomy.  Which is about as visual a course of study as is out there, I would imagine.  It was like trying to memorize not just a map but a road atlas, including the names of all the overpasses and bridges.  For the written exams, there were lists of muscle attachments and organs supplied by each branch of a given nerve I could memorize, but for the practical exam, there was really no hope. 

I went to the prof and was given “study tips.”  I went to my dean and was told not to worry (a saga in itself.)  I was sent to the Adult Learning Specialist and explained to her how I am an auditory and kinesthetic learner with lifelong poor visual processing skills.  She went to her file cabinet and rummaged through it, emerging triumphantly with her “Tip Sheet for Visual Learners.”

“But I’m NOT a visual learner!” I protested.

She suggested I work on my visual skills. 

I pointed out sweetly that while I was more than willing to work on them, I really doubted I was going to get significantly much better in the next 6 weeks than I had gotten in the past, oh, 26 years, and might she possibly have any Tip Sheets for auditory or kinesthetic learners? 

Eventually I managed to pass a written re-exam.  After that, I learned to ask for help early and often for histology and pathology, the other visual fields.  The people who helped me with histo and path were really wonderful sorts.  They were constantly commenting on how good a grip I seemed to have on the material, how I had clearly read the text.  How I was really only asking for help on very few, specific things.  Which is true - I was only asking for help on things I couldn’t learn from the text.  Like how to tell two different pictures apart that looked pretty much like a sea of cells to me.

You know how a picture is supposed to be worth a thousand words?  I’d rather just read the words.

I am fortunate that in most medical settings, I do not have to visually identify people in a vacuum.  Patients generally stay in their rooms, which have names written next to the doors.  Or they are found in clinic rooms, and the chart is handed to me with the room number written clearly at the top.  And they come in a pretty decent array of ages and colors, so if you walk into a room looking for a 2 month old girl, and the room instead contains a 15 year old boy, even I can generally figure out I’m in the wrong place.  (Unless, of course, the 15 year old has actually brought the 2 month old to the doctor, which does happen, but that’s another commentary.)  Many doctors and NPs wear white coats with their names embroidered above the pocket, and employees of all medical settings I have ever experienced are supposed to wear ID tags at all times.

I’m a doctor now.  A real, live doctor, although practicing under a fair bit of appropriate supervision for the next few years.  I feel pretty comfortable taking care of children with trachs and G-tubes, children who have rare genetic conditions I have to look up in the 45 seconds before I enter a patient room, children who take 5 different medications before breakfast and 3 of them preparations I have never heard of before.   I take a good history, my physical exam skills are improving daily, and I consider myself a decent diagnostician given my level of training and experience.  But there are two aspects to general pediatrics which regularly trip me up.

Ear infections and rashes. 

Because there is no history in the world that will tell you if a child’s ear drum is white, grey, red, flat, bulging or retracted.  Either you have a clinical suspicion of ear infection or you don’t, but it’s the exam, not the history that confirms it.  And there is no history in the world that will tell you if the bumps you see before you are hives, no matter how suggestive the history may be of an allergic reaction. 

The result of which is there are a few attending down in clinic who are probably becoming convinced I know absolutely nothing of useful whatsoever, because every time I present a child to one of them, it is either all about a rash or all about an ear infection.

What can I say, if I closed my eyes and the mom described the rash to me, I’d probably be in better shape?  There’s an old joke about the doctor suggesting the patient “hold the rash up to the phone,” but there’s a bit of truth in there for me as well.

Every now and again, the topic of blind physicians comes up.  There are blind physicians out there, I know, although I have yet to meet one in person.  Some attended medical school as blind people, others lost vision after completing training.  And often sighted medical students or physicians express concern about the appropriate of blind doctors, about all the things they can’t do.  About how they have to rely mainly on descriptions of visual phenomena.  Of course I leap to the ADA argument, the “essential functions” argument, the “otherwise qualified” argument.  And all the while I am somewhat envious, because I would probably do much better if I were given those descriptions myself and bypass the visual pathway all together.  But my vision is fine.  20/20, corrected.

A few weeks ago, I got ahold of the map that explains where to park in case of a football game.  The stadium, you see, shares a parking lot with the hospital and the first home game was Saturday.  On Monday I found the alternative parking area behind the hospital but not the route to it I would need to take when the main road would be blocked off.  On Tuesday, I found the alternate road, but couldn’t find the parking area from it.   On Wednesday I got groceries.  Thursday I found the parking area again and then drove out through the alternate road.  Friday, I think I went home.

Early Saturday morning, I made it up through the alternative route to the alternative parking area in the foggy pre-dawn and parked my car.  I was on call, so I loaded up my luggage rack and tried to figure out where I was, wondering where the promised security officers might be.  Luckily I heard the voice of another intern and followed her in.  I worked all day Saturday, and then Saturday night, and was done with my work around 10 AM Sunday, as was the medical student who had been on call with us.  The attending sent him out with the instruction, “Your last duty is to help Dr. [Nightengale] find her car!”

The student was sweet and chivalrous and he did.  We tried where he thought it might be based on my foggy description, only to discover someone else’s slate blue Ford Taurus there instead.  A few minutes later and further away, we did find my car.

But somewhere that week, between the driving and the frantic map-gazing and the wandering, it occurred to me.  DRVSS may not exist, I may not officially have NLD.  But my poor visual processing skills probably impact me so much on a daily basis, that really I think it’s more disabling than asthma, CP, chronic pain and Type 1 diabetes all combined.  

Maybe someday I’ll get  DRVSS recognized after all.