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when doctors can't hear

We have discussed child abuse on this blog before, and I promised you more in a series I began last year. This time I want to tell you a story from when I was a medical student--admittedly some of you will consider this ancient history, and perhaps you should. I do not remember the names of my preceptors or the name of the patient. So there is little chance I will tell you anything I shouldn't. In fact, I don't even remember the name of the hospital where this rotation occurred. Yet I remember the patient, her husband, her daughter as if it were yesterday. 

I was a third year "clinical clerk" on psychiatry.

We admitted a woman, in her mid-20's,  who had been brought into the emergency department by her husband because of her strange behavior. She seemed out of control in the emergency department, and therefore was admitted to the inpatient psychiatric ward for evaluation and treatment of suspected psychosis, felt to be acutely manic and was committed to inpatient care against her will. She was kept in hospital for 7 days, started on medication, but never became docile. She kept asserting that her husband was sexually abusing her 6-year-old daughter. Her husband would come in, demonstrate loving and appropriate behavior toward his wife and daughter, and express dismay that anyone would think him capable of harming his daughter in any way. 

As the week of her commitment was nearing an end, and we were preparing to discharge the patient to her home, I asked the attending psychiatrist and the resident whether we should at least check out the woman's story, just in case there was any truth to it. Could there be some reality that was driving her lapse into mania when she had always behaved typically before? No, they told me. This woman had a serious mental illness, and was fabricating the stories she was telling.  By the time she left for home she was no longer  accusing her husband of abuse.  She was discharged on some medications, I believe lithium and thorazine, with follow up in the outpatient clinic in two weeks. 

She didn't make it to the appointment.

She  was brought into the emergency department a few days later, dead on arrival,  having committed suicide.  A note stated that she couldn't stand by and watch her daughter be abused any longer.  After her death, the investigation revealed that the daughter did have physical evidence of sexual abuse, and the father was identified as having an "antisocial personality." He had tricked us into believing him, and not his wife. She lost her life because we doctors would not speak up, or even listen to her pleas to save her daughter. I was as guilty as the others.

Great story, huh?

Yep. This is one of several "sentinel events" that helped to shape the future doctor I would become. It taught me several very important lessons. The most important was that I need to listen to my heart. When the "gut feeling" is strong, it needs to be listened to. I have had to learn that lesson over and over. Sometimes as a physician, you ask a specialist to provide consultation on a patient. Most of the time, the advice you get is good, and you should follow it. But NOT always. I have had to learn over and over that sometimes what the consultant recommends is not the right thing for that patient at that time. I need to listen to myself, because I may know the patient better than the specialist, even if I am not as knowledgeable about the particular disease process. This doesn't mean I should be arrogant and just do what I want. But it does mean I need to listen to what my gut or my patient is telling me.

The other very important lesson is to listen to what your patient is trying to tell you. Was my patient suffering from a mental illness? Yes. Did that mean that everything she said was delusional? NO! The take home lesson here is to listen, really listen to what a patient, or a parent may tell you. Can parents say things that are not true? Of course they can. And we see evidence of child abuse and neglect all the time, where the parent's description is incompatible with the child's condition. But the point is, someone will be telling the truth, we just may not always know who.

Luckily for me I have never seen another case exactly like this. Not saying I never make a mistake or that I can always discern the truth, but I did become more assertive, even as a medical student, sometimes to the detriment of my written evaluations. But always in the interest of the truth, and in finding and doing what was in the best interest of the patient I was entrusted to care for at the time. It is the only way I was able to sleep at night.

For the students and residents reading this blog,

I hope that you can learn something about the true nature of the physician-patient relationship. Even in the face of mental illness, your patient is the one to whom you owe allegiance, and you owe it to her to find the truth. And of course you owe it to any innocents who are potentially at risk, like the daughter in this story. And, oh by the way, your attending does not ALWAYS know best. We have learned much from our experiences, both good and bad. Hopefully some of our experiences can help to inform your future behavior as well.

For the practicing docs or nurses or other healthcare providers,

Can you relate to this tale? What do you do, if you think the provider in charge of the particular patient case is not seeing the whole story? Do you feel that you can speak up? I hope so, but would love to see your comments below.

For patients and parents,

What do you think? Have you ever been in a situation in which you thought your physicians were not listening, or could not see the truth? Please leave a comment, and let's have a discussion.



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