Things are not always what they seem

Persson, Megan

As a family medicine graduate, I have enjoyed a diverse practice that has included ICU work, locums, both rural and urban, emergency medicine, which was my 3rd year training specialization, and an urban part-time clinic practice where I enjoyed seeing a number of professionals, many functional elderly and a diverse group of their family members. When my emergency medicine colleague approached me to join his clinic, I had been practicing emergency medicine in a downtown hospital for several years, so I was pretty comfortable with acute medicine. While I was catching up on the guidelines that had been updated over those years for the necessary screening for diabetes, hypertension and cholesterol, my biggest challenge was the undifferentiated patient. I had to decide, based on a few, often benign symptoms, whether I needed to work them up in a slower system than I was used to, or follow them up to see if the symptoms had resolved. In an emergency department, often without easy plan to followup but many immediate resources, this was not easy to reconcile. In the clinic, followup was easier (at least at this early stage of my practice) but investigations much slower and the decision to delay would rarely but eventually lead to a delay in a necessary diagnosis. The lesson I was about to learn was even more sobering than that!

The first day I met Anne [the name has been changed to protect privacy], she came in for a checkup. It had been a while since her last one, thanks to her good health, young age, and general dislike of medical exams. She appeared to be a well 30-year- old professional, but quite anxious. In fact, had it not been for a colleague who was a good friend, she may never have presented at this point. Her co-worker had encouraged her to see a doctor who turned out to be me, mostly because of her anxiety.

She was a teacher, and she functioned despite this anxiety teaching those difficult middle years of junior high school. But she had yet to have a serious boyfriend, had a very limited social network outside of school and close family, and for the most part had some traits but no conclusive evidence of an avoidant personality disorder. It seemed that her anxiety was generalized, and since there were no major depressive symptoms or sleep disorder, I discussed seeing her regularly for a few visits to talk more about her life and how she could manage some of her symptoms. Her exam, which was limited mostly to the usual suspects with the exclusion of a gynecologic exam that the patient declined, was normal.

Several months went by, and little changed, and I continued to discuss the same issues and, possibly, mostly due to my failure to know what to do otherwise, we discussed SSRIs as a long term strategy as there was no improvement and perhaps a slight worsening in her symptoms. Anne didn't feel ready to try medications, and for a while she did not followup. The next time I saw her, she was a mess. Her friend had to threaten her in order to have her to come see me. She was clearly much worse. She still denied feeling depressed or having any trouble with sleep, but she was having trouble functioning in school maintaining control of the class and was coming to the staff room at breaks nearly in tears. Her anxiety was not limited to school though, and her reclusiveness was complete, going solely to work and returning home, and not even going to visit her immediate family in the suburbs as she normally would regularly.

Now, obvious to both me and the patient, and not being on any medications, prescribed or illicit, she had a tremor of her hand. At this point, I sent her to a neurologist, thinking she was having a coincidental neurologic problem, and this time convinced her to go on an anti-anxiety medication. Much to my dismay, I did not see her for a couple months.

This, and many other cases, had led me to refer to this as the Megan Maxim: the more worried you are about a patient and their medical or psychological well-being, and the more mental and emotional energy you spend trying to get this across, especially when you deceive yourself in getting a connection with said patient and win their comprehension of your explanations, the more likely it is that they will abandon the treatment plan and rob you of all confidence of your communication skills.

The next time I saw Anne, she was a changed person. Most dramatically, her anxiety, always present since the day we met, was gone. Most remarkably, she had her haircut short and still sported evidence of a craniotomy scar. As it turned out, the neurologist saw her, organized a CT scan of her brain, found a meningioma the size of a tennis ball, referred her for surgery, and the tremor, and anxiety, went away.

To this day, I am humbled by the practice of medicine. Some of our cues are obvious, and others not. Would I have looked harder and seen the cause for this patient’s anxiety if I had met her before her symptoms started? Did my neurologist colleague scoff at my assumption that her two problems were unrelated? Or did I just get lucky to practice the kind of work that can lead to self-congratulation or sleepless nights depending on whether or not, in the midst of a busy day and a thousand decisions and interruptions, I made the right call.

Thank you Anne, and to all the patients we see and learn from daily!

Megan Persson

Theme: Patients | Patients
Theme: Physicians | Médecins
Theme: Teaching and Learning | Enseignement et apprentissage

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.




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