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.
Best Computer: our BRAIN:
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 judgement 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.
Queen Square: 1971
It was an eye opener for me to witness in 1971 a case presentation at Queen Square where a “blind” case was presented to the Professor. I believe it was the tradition then for one of the senior lecturers to present a difficult case that would have been totally unknown to the Professor. A bit like wine tasting. The Professor had no recourse to sophisticated investigations that were widely available today – no MRI and PET scan (PET was at least three years away and MRI, first called NMR, was even later). It was an important lesson for us on clinical skills. The jealous ones had of course dubbed Neurology as 99% diagnosis and 1% cure. Evolutionists proclaim that it is encoded in our genes to self-destruct in cases of nervous system damage. Neurologists are faced with this scenario day in and day out. No wonder some of them get a bit strange. The odd Stephen Hawking does not compensate for the thousands that perish from Motor Neurone Disease everywhere in the world.
The lecture hall was packed with many visiting clinicians from other countries. I was sitting between an American and an Australian.
The “blind” case was a woman with pain in the toe as the presenting symptom. Nowadays she would most likely be given a psychiatric diagnosis and might even be started on Olanzapine or Prozac or both. However, at the end of the session she was given a diagnosis of a lesion in the Thalamus area. It was later confirmed – I knew because I was working there at the time. Whether the lesion was treatable or not was not really the point and it certainly was not the point of Neurology. At least she was spared of the side effects of some of the psychiatric drugs.
The advent of PCT (Primary Care Trust) is so divisive for the National Health Service in U.K. Referrals to specialists are now vetted by a group of doctors. I doubt if a patient with pain in the toe will ever be referred. To us specialists, there is a need to limit prescription of specialist medication such as those in psychiatry to the specialists themselves. There have been some restrictions but often not for clinical reasons. Such measure will be more beneficial to patients than the proposed validation by the General Medical Council.
In a recently published book, the author described how she ‘was dismissed as an alcoholic when her symptoms were blatantly that of multiple sclerosis.’
Too often, instead of keeping an open mind, one finds it too easy and necessary to try and fit things into one’s narrow way of thinking. That could become dangerous when it is the doctor who is doing it.
Modern medical schools:
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 GPs, 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?
Dilemma of free Health Care:
Health planners seem to assume that most that turn up at GP 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 GPs 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!”
Rachel could not get to school. She was having such bad back pain. Her family doctor wrote an urgent referral. As she would not see the psychologist at school, school was considering taking mother to court.
There was a change in managing school refusal. Education Authorities suddenly turned trigger happy and all over the country parents were taken to court. I did wonder if this was due to a shortage of Educational Psychologists who were now too busy dealing with Formal Assessments as a result of the new Education Act, or whether it was due to years of public criticism of the inadequacy of the softly softly approach to the problem. There is some truth that there is a hard core of children whom no teacher really wants to see at school and the authorities are quite happy they are absent. These are children who are entitled to free meals and the hidden saving of them not attending school adds up to a pretty substantial sum. To assess them would take up precious Psychologist time and also may generate expenses in terms of ferrying these children by taxi to special tutorial units or schools.
But Rachel came from a professional family. Mother was a lawyer and father an insurance executive commuting to London. Yes, Rachel had some problems a year earlier because of her height. She did stop attending school for a while, claiming she had pain in her back. She was way over the 98th percentile for height. Some strong pain killer prescribed by her doctor seemed to have done the trick and she had not been absent until the present attack of pain.
Clinical judgment is indeed a kind of “profiling”. We judge our patients from a variety of information and we “profile” them. It may not be correct but we do.
I had my suspicion that the Educational Psychologist never got to see her record to realise that she was not really the type anyone should ever dream of prosecuting.
Last shot by Child Psychiarist:
The family doctor thought that I should be given a shot before anyone should have a go. Mother was told in no uncertain term that she needed to get Rachel to see me.
“But she was in such pain!” mother said. She did protest but in the end succumbed. With the help of a neighbour, they managed to get her to the clinic and she was lying down in our waiting area.
I had one look at Rachel, perhaps 6 ft tall, lying flat in the waiting area and asked my secretary to call an ambulance whilst I talked to the Radiology Consultant. An X-ray examination was ordered and if necessary an MRI scan.
How could I come to such a decision without even spending half a minute with mother or the patient? Was I being over dramatic? Or was it what we have been trained for? Was it why psychiatrists are trained as doctors first?
I could of course have been entirely wrong and the girl might really have been school phobic. Would I have subjected her to an unnecessary X-ray examination? Would my reputation suffer as a result?
The ambulance came. The paramedics were excellent. They treated it as potential spinal injury and transported her that way. I accompanied her onto the ambulance. You had to see her face to know you were right. She was grateful someone believed her. For me it was worth all the drama. My only wish was we were not too late that she might not be able to walk.
Mother too shook my hand as the ambulance got ready to go. I always told my juniors. “Trust them, most of the time.”
Not bad for a Child Psychiatrist:
I left a message for the radiologist to call me.
The call came back from the radiologist. She had two collapsed vertebrae, a common condition among very tall children who have just had a growth spurt. The Orthopaedic Surgeon was preparing for an emergency operation.
“Good work.” The radiologist said.
I knew. He meant: “Good work for a Psychiatrist, and a Child Psychiatrist at that.”
Some time later mother arranged to see me to tell me in detail what was done.
“She wants to thank you for believing her.”
I was just doing my job.
Adapted from The Cockroach Catcher: Chapter 40 It May Not Be All In The Mind
Witch Doctor: Correcting a big mistake?
Dr No: The Apothecary: You’re Fired