As the sun sets.............
©2012 Am Ang Zhang
I have often wondered if it would be such a disservice to mankind if doctors were not so understanding of the psychological side of things.
The possibility of a serious illness being missed is of course a major concern when a patient seeks help for one reason or another. To put psychological conditions at the top of the list of possible diagnosis is dangerous. Given the concern over cost in most health care systems, the need to restrict the use of expensive investigation is understandable. However, with clinical reliance on sophisticated investigations especially in modern medical training, the art of physical examination is perhaps lost to this generation of newly qualified doctors. Moreover, the reliance on the internet for information removes the need to make use of the still most powerful computer of them all – the brain. No more effort is made to attempt to download the information into our brain for future parallel processing. As a result, vital and glaring clues are often missed and, worse, dismissed because of over-saturation of information.
The idea that modern medical training requires some time spent in far-flung places where even the stethoscope is a luxury item is a neat attempt to remind future doctors of the importance of clinical judgment based on physical examination. Unfortunately feedback from medical students that I had the good fortune to teach only confirmed my worst fears. Such attachments are more a chance for them to visit exotic places in the midst of a busy course than to hone the skills of medicine on which their seniors were brought up.
When I first started in psychiatry in
Hong Kong, I was fortunate enough to work
with a consultant who had a very firm grounding in General Medicine. A case I
shall never forget was a thirty-five year old man presenting with very sudden
phobic symptoms. At the time we had just opened in Kowloon our new District General Hospital
Acute Psychiatric Unit with thirty acute beds, shared equally between Males and
Female admissions. This allowed for some acute screening before the long trek
to the only mental hospital in the colony, which was twenty two miles away in
the . To many visiting relatives,
twenty two miles is a long way, especially in the seventies. As we were all
part of one big organisation, it was not really a problem to have screening and
then transfer only if it became necessary. New Territories
It was important to carry out a thorough physical examination on all patients including a thorough neurological test. This particular patient checked out normal on most things except for a positive Babinski (a reflex that can identify disease of the spinal cord and brain) . I was totally baffled but instead of dismissing it I asked my consultant to have a look on the morning round. He carried out a full Neurological.
“Yes, positive Babinski.”
Now how on earth can positive Babinski be related to phobic symptoms?
“We shall need an X-ray urgently, but whatever it is it is not psychiatric”, he declared.
The patient was found to have a special type of very aggressive lung cancer, with extensive metastasis.
He died within six weeks despite some very aggressive treatment at the time.
The sad thing about the case was that being right may not in the end change the outcome. It bore witness to how little we do know and how little we can do even when we do identify the problem.
This case definitely established a principle for my clinical practice. Psychological diagnosis need not be the first diagnosis. Rule out organics first.
Modern medical schools on the other hand pride themselves in concentrating on the role of psychology in bodily dysfunction. It is arguably true that most family doctors do not get to see all the obscure cases we spent so much time studying as a medical student. Yet in time these cases do get to the hospital to be seen by the specialists. Where indeed do they come from? Are they not referred by the family doctors, or are they simply missed and then picked up by the specialists?
Do we as psychiatrists think that it is such a brilliant idea to think “psychology” all the time? Do we really think that people want to see their doctor even when there is fundamentally nothing wrong with them? Is there a grave danger in that assumption?
Health planners seem to assume that most who turn up at Family Surgeries have nothing seriously wrong, and similarly those who turn up at A & E. The latter group are just there because they could not be bothered to see their Family Doctors earlier.
Do we need to apply the money test? Charge a small fee for every consultation for any new condition to exclude malingerers, a sort of “deductible”, in insurance terminology?
Would it not be safer for all concerned that we should remember: “It may not be all in the mind!”
From: The Cockroach Catcher Chapter 40 It May Not Be All In The Mind
Lisa Smirl, 37, saw three different doctors after she began experiencing a range of symptoms including shortness of breath, wheezing and pain in her arm over the course of a year. But they were all dismissed as anxiety and depression.
By the time the cancer was finally diagnosed it had spread into her brain, bones and liver and was terminal.
In a blog written during her treatment,
Cambridge-educated Dr Smirl wrote:
"How is it possible that a 36-year-old, health [obsessed] conscious,
occasionally social smoking, middle class, fiancée of a doctor can develop
metastatic lung cancer unnoticed. How?!?"
"For the last year I'd been battling a range of bizarre and seemingly disparate symptoms that had forced me in September 2011 to go on sick leave from my job as a lecturer (assistant professor).
"The diagnosis at the time was anxiety and/or depression. And while I was both anxious and depressed, this was due to the increasingly disabling symptoms that my doctor kept insisting were purely psychological.
"So I was actually grateful for a medical diagnosis that confirmed there were objective, physical reasons behind my illness.
"While in some ways this was a terrible surprise, in another it was a huge relief."
Dr Smirl, who is originally from Canada, first experienced shortness of breath and wheezing in late 2010, which was wrongly diagnosed as asthma.
By September 2011, after developing shoulder and arm pain and experiencing 'visual migraines' – in which she lost her vision for half an hour – Dr Smirl was forced to leave her job. She was diagnosed with depression and anxiety and put on antidepressants.
But despite a dramatic weight loss, Dr Smirl claimed three different family doctors refused to consider her symptoms in connection with each other.
In November 2011, a year after she first started having symptoms, she was finally diagnosed with cancer after a doctor agreed to send her for an X-ray.
Dr Smirl, who went on to complete the Great North Run to raise funds for a cancer charity in November 2012, wrote on her blog: "I can't prove it, and this is just my opinion, but I have no doubt in my own mind that my misdiagnosis was in large part due to the fact that I was a middle aged female and that my male doctors were preconceived towards a psychological rather than a physiological diagnosis.
"It is so easy to say that someone's symptoms are 'anxiety' related if they are a little bit complicated, unclear or unusual. Don't repeat my mistakes.
"You know when something is wrong. Find another doctor that you connect with and who takes your concerns seriously. Get referrals. Get tested. Refuse to be dismissed."