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The first step in diagnostic questioning involves knowing what you're dealing with. Teresa Gardner is an expert at that. She's been celebrated by her peers, which is how I heard about her and tracked her down, and she's been profiled on national television. Fearless, tireless and endlessly resourceful, Teresa works in one of the most impoverished parts of America.

A nurse practitioner who makes her rounds through the hills and hollows of the Appalachian Mountains in southwestern Virginia, Teresa deals with what she calls "human train wrecks." Many of the people here are poor and chronically ill. They lack access to jobs and healthcare. Unemployment rates in many areas are twice or more the national average. Many eat poorly, get inadequate exercise, and neglect themselves in the scramble to make ends meet.

"It's an area of desperate need. But the people here are such good people," Teresa told me. Most are hardworking and proud. "Our patients are some of the nicest people you'd ever meet. They're down on their luck," but, she confides, "sometimes we have trouble getting people to accept help."

They need the help. Residents in this part of Appalachia experience disproportionately high rates of heart disease, diabetes, and pulmonary disease. Some counties report twice the early death rates as the rest of the state. Teresa spends her days on the move. Responding to the bottomless pit of need, she took her practice on the road, in the early years driving around in a beat-up old Winnebago called the Health Wagon. Her patients often had not visited a medical professional in years. But Teresa welcomed them with open arms and warm spirit, examined them, listened to their stories, diagnosed their illness, and prescribed their medication.

She used her questions like a scalpel, short and sharp, to cut to a problem to identify and try to fix it. She started with open-ended questions to get people talking and to prompt a description of the problem.

How are you feeling?
What are your symptoms?
How long has it been like this?

Teresa asks her patients about a lot more—their work and their home, their families and their lives, how they're eating and what they're drinking. She listens for clues pointing to the root of the problem. As she asks, she brings instinct, experience, and expertise to bear. She's been practicing since she was young.

Teresa grew up in this part of the country, in Coeburn, Virginia. She shared a tiny room with her sister in the trailer that was the family home. Her father worked in the mines, her mother in a sewing factory. Her dad had a bad back, and some days the pain was so acute, he would fall out of his truck at the end of the day and crawl to the front door.

While the family didn't have much, they had more than many, and they helped where they could. Her grandmother, "Mamow," a plump woman who lived nearby, opened her home to feed and occasionally  house sick neighbors, some suffering from tuberculosis. Teresa's mother took meals to the local hospital. Teresa volunteered at the hospital, too.

A curious child from the time she was little, Teresa peppered her mother with questions about how things worked, where they came from and why. She asked about places and people. Her mother nicknamed her "Miss Nosy." Teresa took her inquisitive nature to school. She recalls the day her sixth-grade teacher, Mr. Bates, drew a heart on the blackboard and started explaining how it had chambers and valves and pushed blood out and through the body. She was mesmerized and wanted to know more about how the heart worked. How did it know how much and how fast to pump? She developed an interest in science and started reading magazines, books, articles—anything she could find about medicine and biology.

She became the first in her family to go to college and ultimately earned a doctorate in nursing practice. Then she came home. She wanted to work in the place where she was raised and where she knew her help was needed.


Trekking across this complex terrain of geography and human need, Teresa elicits vital information from people who are often reluctant to talk. Her warm Virginia accent softens her questions, but they are nonetheless deliberate and focused. Teresa expects a detailed description of what hurts and where. She seldom wastes time or words. Often the problem is buried deep.

Teresa pulled the Health Wagon into Wise, Virginia, shortly before lunch one day, and a woman climbed aboard. She was short and overweight and in her early twenties. As usual, the first question was big and open and warm. With a smile she asked:

How are you doing today?

Not well, the woman said. Her head hurt. She was feeling tired and weak. She felt confused, disoriented. Teresa asked about her past health issues. The woman said she'd suffered from high blood pressure, chronic weight issues, and diabetes.

Teresa suspected the woman was having a diabetic attack. Her questions grew more specific and urgent, homing in.

What medicines are you on? What dosage?
When was your last insulin injection and last meal?
What are your other symptoms?
How long have you had diabetes? Is it Type 1 or Type 2?
When was your last lab work?
What has your insulin regimen been for the past few days?

The answers came in short, hesitant responses. But they added up. A blood test confirmed it: The patient was suffering from hyperglycemia. The treatment for diabetes and high blood sugar is straightforward. Strict diet and carb counting. Insulin, closely monitored. Regular doctor visits. The patient failed on all counts. She was taking insulin but wasn't sure of the dose. She hadn't been to a doctor in two years. Teresa wanted to know what was going on and why.

This excerpt ends on page 15 of the hardcover edition.

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