One thing that often frustrates me is the difficulty in trying to understand my patient. This happens more frequently than I would like to it to be. More worryingly it often passes under my radar of self-awareness. It can be hard to resist the relief of giving a “diagnostic label” and treat that label.
What follows is an extract from a book that has been a great solace and inspiration. After a hard day this has helped me recharge my soul and return to work the next day rejuvenated. Thankfully, most patients I see are nowhere as daunting as Florence. Or, may be they are and it is my lack of imagination that is the limiting factor.
I hope you will find it inspiring as well.
“I am Florence’s mother, I am a paranoid schizophrenic and she is too. This is her husband, whom I despise. What do you mean by telling Florence she cannot see another doctor?”
Florence’s list of symptoms by the end of sixth week of visits included:
Itching ear canals
Deep pain in her throat
Shortness of breath
A dull chest pain
Fullness after eating
Pain with menses
Burning on urination
Pain on swallowing
Aching lower legs, arms, thighs, and shoulders
Crawling sensations under the skin of her face
Intolerance to several foods
Spots in her field of vision
Swelling of her hands and feet
Red blotches on her neck
Hair falling out
Weak spells but no loss of consciousness
A feeling of impending doom
Sensations of being hot and cold
Tingling sensations in her legs
Decreases in visual acuity that would come and go
Episodes of severe abdominal pains
Loss of energy and tired feelings
Feeling sick all over
She told me early that she was absolutely convinced that she had a very rare disease that was beyond medical science. I…kept telling her, “I do not know what is wrong with you…yet.”
I never told her that “nothing was wrong” with her. I also resisted the common course of telling such a patient that the problem was “all in your head.”
There were at least two other prevailing strategies for dealing with patients with many symptoms. The, first, and the most dangerous, was to make a diagnostic error and assign a false diagnosis to the patient. The other common way of dealing with these patients was to make up an innocuous diagnosis and assign it to them. What I was attempting with Florence was to abandon all these common approaches, stay completely honest, and see where it led.
I now had a very long list of diseases I knew she did not have, and in some sessions, I would read the list very slowly to her. I would go on and on in boring details, dragging out my list of absent diseases.
Then one day as I was going down the list of diseases I knew she did not have, she started to laugh. She laughed, and laughed until her eyes were watering. I waited. After she collected herself, she said, “Okay, this is getting ridiculous, it’s ludicrous, that’s what it is. It’s ridiculous.” She looked very puzzled and sat there saying nothing, staring out of the window.
I must have waited ten minutes. I could hear Sapira in my mind’s ear. “Hold out…hold out…use pauses; let the patient speak first whenever possible.” it was like holding my breath too long under water. Then she said, with some hesitation, “I need to think. I’ll see you next time,” and she left. This occurred at the end of ninth month.
The next time she came in, she looked very different from any time before. “What do you think you have?” I asked.
“I think I have lice under the skin of my body, and I know they are eating my hair follicles.” She blushed and looked embarrassed.
I asked her what test she thought I should do to prove the diagnosis right or wrong. She went on to tell me that she wanted me to biopsy her skin and find lice.
“What else might convince you that lice infestation was the one and only disease that you have or would convince you that you do not have lice? What can I do that would do that for you?”
She thought for several minutes and said, “Treat me for lice and I will be satisfied.”
After much thinking and soul searching, I came to a decision. I had pharmacist prepare a very dilute solution of Qwell lotion. On the next visit, I wrote her the one and only prescription I had written for her in the nine months I had been seeing her. I suggested she apply the lotion to her whole body twice daily for ten days. I did not want her to miss a spot, so I spent some time telling her exactly how she should apply the liquid. I put myself into whatever mental gear I thought might increase the potency of the placebo, if a placebo was going to work here.
She smiled as I handed the prescription to her, and then she said, “But you do know, don’t you, that you must treat again in two weeks to kill the eggs that hatch after the first treatment?”
Florence returned with her husband. Both were all smiles. She looked like an entirely different person – confident and very outgoing. She often deferred to her husband, who thanked me again and again.
Both talked about their future. He was going to go to graduate school, in geology, I believe. She would finish her Ph.D. In history and had a job lined up with the university library research department.
We did not talk of any symptom nor did I ask Florence how she felt.