Monday, July 23, 2007

Stolen moment, shattered life

"Before you interview this next patient, Vitum, there's something you should know."

"Sure, what is it?"

The doctor closed the door to his office, and handed me the patient's chart.

"This patient came to me a couple of years ago. He's a very successful architect, he lives downtown, and he's overall quite healthy. But before you go in there, I just wanted to give you the heads up - he was sexually assaulted when he was a young boy. Just, you know, so if anything along those lines comes up in your interview you can be sensitive to that."

Ha, I thought. Warning me so that I don't put my foot in my mouth.
Again. I guess he knows me better than I thought.

I appreciated the warning, even though the patient was there for something entirely unrelated and that issue never came up in the interview. The guy was obviously very successful, clean-cut, and seemed quite confident and professional. He took good care of himself and seemed to have a really good head on his shoulders. I wrapped up with the interview pretty quickly, told him the doctor would be in to see him, and then went back to the doctor's office.

When the doctor is with another patient and I'm waiting, I'll generally review my class notes if I've got them, brush up on a few drugs, look over the drug samples in the office wondering if I could just take some pills just to try them out. Or I'll look over the various diagnostic journals piled high on the doctor's desk, or read a patient's chart if I've got it. Not really thinking of the warning the doctor had given me, I habitually cracked the patient's chart and began reading.

In just a few minutes, what I learned about the lingering effects of child abuse will stay with me forever. I caught a snapshot of how a brief moment stolen from this poor man's childhood has in one way or another affected every aspect of this patient's life.

The chart read like a paperback story that would be too depressing to ever make it to print. It was packed full of the effects about how this patient's life had been dramatically and irreperably changed because of this incident. Here were the carbon copies of emergency room charts depicting the patient's multiple visits for anxiety attacks, thanks to post-traumatic flashbacks of the experience. There were the notes from a psychiatry consult that the patient had undergone shortly before, which contained more terrible, heartrending details of not so much the experience, but how it had affected him.

The patient had initially told his brother, his closest friend, about what their hockey coach had done to him. His brother's response? He didn't believe him. That's pretty much the worst thing you can do if someone approaches you saying they've been assaulted. After that, the patient didn't bother telling anybody else about it, until he needed to seek medical attention for the stress; even still, there are only a few people that he's told.

Now, he suffers from frequent flashbacks, most of which land him in the ER with anxiety attacks. He has trouble with commitment (more than the average guy) or sexual intimacy - I wonder if he'll ever be able to settle down with someone. He can't be alone in a room with an older male - must be hard to have a job interview under those circumstances. He can't have anything to do with hockey games, arenas, or the game in general - that must make it difficult to go to a bar with the guys.

I had heard that sexual abuse can be a tragedy that significantly affects a person's life, but I had had no idea that it was that pervasive. My heart went out to this patient when I finally went in with the doctor. I was one of maybe five people on earth that knows about his secret, and as much as I wished I could do something to help him get back to a normal life, I couldn't. All I could do was be shocked at how unbelievable it is that one brief, disgusting, selfish action that lasts a brief moment can literally ruin a victim's life. It literally made my stomach turn.

The worst part is, the creep who did this is still free, probably still working with young kids, quite possibly still assaulting children, ruining lives by taking one moment at a time.

One of the things that attracted me to medicine is how a doctor is much more than just one thing - a doctor is an expert in chemistry, biology, pharmacy; a manual labourer, a thinker, a problem-solver; a teacher, an advocate, a counsellor. I'm not sure, but judging by how nervous I am to have to someday be the listening ear to someone who confides in me the details of their painful past, that last one might be the hardest one.

While this story is based on an actual experience I had in a hospital, and the effects of sexual assault on a person are real and devestating, the patient and experience depicted here is entirely fictional. Confidentiality of my patients is my highest priority, just as it would be if you were my patient. For more info, please see the disclaimer at the bottom of the page.



8 comments:

cardiogirl said...

That is a terrible story. I have wondered how doctors with a good bedside manner handle the line between empathy and sympathy. How to be a listening ear without getting sucked in to other people's problems.

I have not been successful at that. However, I am not a doctor, so I guess it doesn't matter.

gay CME guy said...

When I read posts such as this and Graham's "Over My Med Body" (http://www.grahamazon.com/), it restores some of my faith in humanity and the future doctors we are training. It's the human touch/bedside manner that makes an excellent clinician a great physician. Conversely, it's the absence of said manner that makes an excellent clinician a crappy physician. I have worked with and been treated by both types. "First do no harm", is not relegated only to physical conditions. It's ok to get 'sucked in', and I would argue it's necessary at some level. Not letting it consume you, is how you maintain the balance, a be the excellent physician, not just a clinician.
Keep up the excellent work.

aherbalist said...

"Stolen moment shattered life" made me feel more optimistic about the state of medical education and the level of empathy of the people we are training to be doctors. I tutor in a medical school course and I was floored by a student who asked if there was "ever" an occasion where patients with anxieties/phobias evaded good medical attention by their avoidant behaviour. And how did I feel about them evading good treatment!
I felt the full weight of my middle-aged, non-medically trained self: and I wondered if these bright, shiny students full of idealism and the desire "to do" things to help, realise just how difficult their profession to be can be on the emotional level? How often one can feel helpless in the face of patients' pain and distress. The complex long-term outcomes of violence and abuse have effects that last a life-time and sometimes the best you can do as a practitioner is bear witness to the patients' pain.
It's not a case of whether you get to feel helpless in the face of patients' pain "ever" but just how often it happens and how much you let it in.

LadyUK said...

I couldn't seperate from the emotion cardiogirl.

There comes a time in every doctors career when they have to decide if they can seperate, and if they cannot, will they be able to cope?

Some can, some can't, and some change careers.

You are a much stronger person than I am, sticking with it and helping others.

I hope that this patient finds some comfort and good coping mechanisms to deal with his trauma.

Derrick said...

The story is horrible, but one thing that bothers me is the fact that you were reading it at all. It seems from your post that you were simply bored, and perused a chart that you had no business reading. In addition to being against the law, it is simply immoral. The patient expects that when he shares information like this that it won't be used to "entertain" a bored staff member in an office.

I think that it is time for a refresher on HIPAA and patient confidentiality. Tsk Tsk!

Vitum Medicinus said...

Derrick - Good call. I certainly felt a bit guilty after peering into the deepest secrets of this patient's life, and obviously you are feeling the same way I did. And, I knew that readers of this post might not necessarily feel comfortable about what happened to this patient, and that they might not feel comfortable knowing about it. I'll tell you what I did want readers to feel in a bit. But first, I'll explain why I was reading this patient's chart.

I wasn't trying to discover juicy secrets. The doctor did make a point of telling me about this patient's history (as he does with almost every patient), and believed it was something that I should know about, given my responsiblities to the patient (even though they are limited at this point in my training).

Clearly, by telling the medical professional about this issue in the first place, the patient was giving consent that this information should be in his chart. And, before I interview any patient, I always make it clear that I'm a student, not a doctor, and I always gain consent (always asking twice, in two different ways) that they are willing to be in my care and confide in me.

I also respect that when one reads this story they may have come under the impression that I specifically wanted to read this patient's chart, and may picture me maliciously rushing to the office to uncover this patient's secrets. To be honest, when I compare my experience with this patient with most of my other patients, I didn't really spend much more or less time reading his chart than I spend on the charts of many other patients. Especially when the doctor had said things like "This patient has had a history of lupus and has seen many specialists," I have been just as inclined to read the patient's chart to determine how the patient first presented and that conclusion was reached - a vital component of learning medicine.

Reading charts provides me with important background for understanding a patient interaction. What are their latest lab results? What has a specialist said about the nature of this patient's condition? Why are they on atenolol and not metprolol, two drugs of the same class? Has their diabetes been getting worse in symptoms and requried medical management? Could the number of medications this patient is on - and how often they've been changed - be a reason for their frustration with the doctor? Maybe their stomach pain isn't appendicitis because their appendix was removed when they were 14 - and they didn't remember to mention it when they listed off the 17 operations they have had over the course of their lifetime.

Additionally, charting is an important skill of any doctor, and I have learned many things from reading charts of other doctors. In this time of increased medico-legal action, learning to chart well can be supplemented by finding out how much information you can get by reading another doctor's depiction of a patient interaction. "Do I know what really happened when this doctor interviewed the patient, or did the doctor leave anything out? Is this doctor's account vague or well-detailed? Are there any details that I am left wondering about?"

As well, I have found the reports of specialists extremely useful for a number of reasons. First, it helps me realize the way physicians communicate - the language they use, how they describe their history and physical, when they mention patient demeanour or other incidentals, and the template of their correspondence. Secondly, it helps me understand their thought process as they see a patient who has been referred to them under suspicion of a certain condition, and how they rule out or confirm that diagnosis.

The reason I wrote this post is because I wanted to emphasize my shock and horror at the extent to which this event impacts every part of this patient's life, even years afterwards.

And, I wanted to also get the word out that not believing a friend who confides in you that they have been assaulted is the worst possible reaction you can have.

But you raise a good point that, without explanation, could be a reasonable conclusion. Next time I fabricate a story for this blog, I'll consider being more creative when I come up with a way to say how I obtained the patient's past medical history.

In the mean time, when you are participating in your weekly clinic rotations, I encourage you to pay more attention to what the doctor writes in the patient's chart, and what other specialists have said about your patient, and discover how your understanding of a patient's context and the level of care you provide for that patient can be deepened by reading the contents of that patient's chart.

comrade said...

A medical student who has the permission of the patient to be privy to his case in order to learn the practice of medicine hardly seems to be a "bored staff member" looking for kicks. Further, if a patient has consented to allowing the student into his confidence for the purpose of his education as a doctor, it seems plainly obvious that one of the things he should be doing is reading the patient's medical history -- you know, like a doctor would.

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