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.
Hong Kong:
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 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
Daily Telegraph:
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
"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."
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